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MANUALS 

FOR 

STUDENTS    OF     MEDICINE 


Surgical 
Applied  Anatomy 


BY 

SIR  FREDERICK  TREVES,   Bart. 

G.C.V.O.,  C.B.,  LLD.,  F.R.G.S. 

Serjeant  Surgeon  to  H.M.  the  King;    Consulting  Surgeon  to 

the    London    Hospital ;    late    Lecturer   on   Anatomy   at  the 

London  Hospital. 

SIXTH   EDITION,   REVISED  BY 

ARTHUR  KEITH, 

M.D.,  LL.D.  Aber.,  F.R.G.S.  Eng. 

Hunterian  Professor  and  Conservator  of  the  Museum.  Royal 
College  of  Surgeons  of  England  ;  formerly  Lecturer  on  and 
Senior  Demonstrator  of  Anatomy  at  the  London  Hospital  ; 
Examiner  in  the  Universities  of  Aberdeen,  Cambridge,  etc. 


Illustrated  with  137  Figures 
including  58  in  colour 


LEA    & 

PHILADELPHIA 


FEBIGER 

AND     NEW     Y  O  It  K 


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QM53I 
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PREFACE   TO  THE    SIXTH   EDITION 

Although  many  additions  have  been  made  to 
and  minor  alterations  effected  in  the  present 
edition,  this  book  still  retains  the  spirit,  form, 
and  size  given  to  it  by  its  distinguished  Author. 
The  chief  alterations  in  the  new  edition  relate 
to  glands  of  internal  secretion,  to  the  lymphatic 
system,  to  the  anatomy  of  the  abdomen,  and  to 
new  facts  which  have  been  discovered  by  the 
use  of  X-rays  in  examining  the  human  body. 
Thirty-five  new  illustrations  have  been  intro- 
duced, many  of  them  in  colour.  In  preparing 
new  figures  and  in  revising  the  text  the  Editor 
has  been  assisted  by  Dr.  S.  J.  A.  Beale. 

Arthur  Keith. 

The  Museum , 

Royal  College  of  Surgeons  of  England. 


8661 


PREFACE    TO    THE    FIRST    EDITION 

Applied  Anatomy  has,  I  imagine,  a  twofold  func- 
tion. On  the  one  hand  it  serves  to  give  a 
precise  basis  to  those  incidents  and  procedures  in 
practice  that  more  especially  involve  anatomical 
knowledge  ;  on  the  other  hand  it  endues  the  dull 
items  of  that  knowledge  with  meaning  and  interest 
by  the  aid  of  illustrations  drawn  from  common 
medical  and  surgical  experience.  In  this  latter 
aspect  it  bears  somewhat  the  same  relation  to 
Systematic  Anatomy  that  a  series  of  experiments 
in  Physics  bears  to  a  treatise  dealing  with  the 
bare   data  of  that  science. 

The  student  of  Human  Anatomy  has  often  a 
nebulous  notion  that  what  he  is  learning  will 
sometime  prove  of  service  to  him ;  and  may  be 
conscious  also  that  the  study  is  a  valuable,  if 
somewhat  unexciting,  mental  exercise.  Beyond 
these  impressions  he  must  regard  his  efforts  as 
concerned  merely  in  the  accumulation  of  a  number 
of  hard,  unassimilable  facts.  It  should  be  one 
object  of  Applied  Anatomy  to  invest  these  facts 
with  the  interest  derived  from  an  association  with 
the  circumstances  of  daily  life ;  it  should  make 
the  dry  bones  live. 

It  must  be  owned  also  that  all  details  in 
Anatomy  have  not  the  same  practical  value,  and 
that  the  memory  of  many  of  them  may  fade  with- 
out loss  to  the  competency  of  the  practitioner  in 
medicine  or  surgery.  It  should  be  one  other 
object,  therefore,  of  a  book  having  such  a  purpose 
as  the  present,  to  assist  the  student  in  judging 
of  the   comparative   value   of  the   matter   he   has 


viii  PREFACE 

learnt ;  and  should  help  him,  when  his  recollection 
of  anatomical  facts  grows  dim,  to  encourage  the 
survival  of  the  fittest. 

In  writing  this  manual  I  have  endeavoured,  so 
far  as  the  space  at  my  command  would  permit, 
to  carry  out  the  objects  above  described ;  and 
while  I  believe  that  the  chief  matters  usually  dealt 
with  in  works  on  Surgical  Anatomy  have  not  been 
neglected,  I  have  nevertheless  tried  to  make  the 
principle  of  the  book  the  principle  that  under- 
lies Mr.  Hilton's  familiar  lectures  on  "  Rest  and 
Pain." 

I  have  assumed  that  the  reader  has  some  know- 
ledge of  Human  Anatomy,  and  have  not  entered, 
except  in  a  few  instances,  into  any  detailed 
anatomical  descriptions.  The  bare  accounts,  for  , 
example,  of  the  regions  concerned  in  Hernia  I 
have  left  to  the  systematic  treatises,  and  have 
dealt  only  with  the  bearings  of  the  anatomy  of  the 
parts  upon  the  circumstances  of  practice.  The 
limits  of  space  have  compelled  me  to  omit  all 
those  parts  of  the  "  Surgery  of  the  Arteries  "  that 
deal  with  ligature,  collateral  circulation,  abnor- 
malities, and  the  like.  This  omission  I  do  not 
regret,  since  those  subjects  are  fully  treated  not 
only  in  works  on  operative  surgery,  but  also  in 
the  manuals  of  general  anatomy. 

The  book  is  intended  mainly  for  the  use  of 
students  preparing  for  their  final  examination  in 
surgery.  I  hope,  however,  that  it  will  be  of 
use  also  to  practitioners  whose  memory  of  their 
dissecting-room  work  is  growing  a  little  grey,  and 
who  would  wish  to  recall  such  anatomical  matters 
as  have  the  most  direct  bearing  upon  the  details 
of  practice.  Moreover,  it  is  possible  that  junior 
students  may  find  some  interest  in  the  volume, 
and '  may  have  their  studies  rendered  more  in- 
telligent by  learning  how  anatomy  is  concerned 
in  actual  dealings  with  disease. 

Frederick  Treves. 

September,  1883. 


CONTENTS 

PART  I.-THE   HEAD   AND   NECK 

CHAPTER  PAGR 

1.  The  Scalp 1 

2.  The  Bony 'Vault  of  the  Cranium  ...  17 

3.  The  Cranial  Contents 31 

4.  The  Orbit  and  Eye   .       .   .   .    .50 

5.  The  Ear 82 

<;.  The  Nose  and  Nasal  Cavities  ....  98 

7.  The  Face 116 

8.  The  Mouth.  Tongue,  Palate,  and  Pharynx  .  143 

9.  The  Neck 165 

PART  IL-THE   THORAX 

10.  The  Chest  and  its  Viscera        .  203 

PART  III -THE   UPPER    EXTREMITY 

11.  The  Region  of  the  Shoulder  ....  224 

12.  The  Arm ,264 

13.  The  Region  of  the  Elbow         ....  272 

14.  The  Forearm 291 

15.  The  Wrist  and  Hand 300 


x  CONTENTS 

PART  IV.-THE    ABDOMEN   AND   THE   PELVIS 

OHAPTKtt  PAGE 

16.  The  Abdomen 332 

17.  The  Abdominal  Viscera 371 

18.  The  Abdominal  Viscera  {concluded)         .        .414 

19.  The  Pelvis    . 445 

20.  The  Perineum 455 


PART  V -THE   LOWER   EXTREMITY 

21.  The  Region  of  the  Hip 502 

22.  The  Thigh 540 

23.  The  Region  of  the  Knee 548 

24.  The  Leg 570 

25.  The  Ankle  and  the  Foot 587 

PART  VI.-THE   SPINE   AND   SPINAL  CORD 

25.  The  Spine 627 

27.  The  Spinal  Cord .638 

INDEX 653 


Surgical  Applied  Anatomy 


pART  i._ the  head  and  neck 

CHAPTER    I 

THE    SCALP 

The  soft  parts  covering:  the  vault  of  the 
skull  may  be  divided  into  five  layers  :  (1)  the 
skin,  (2)  the  subcutaneous  fatty  tissue,  (3)  the 
occipito-frontalis  muscle  and  its  aponeurosis,  (4) 
the  subaponeurotic  connective  tissue,  and  (5)  the 
pericranium.  It  is  convenient  to  consider  the 
term  "  scalp  "  as  limited  to  the  structure  formed 
by  the  union  of  the  first  three  layers  above  named 

The  skin  of  the  scalp  is  thicker  than  m  any 
other  part  of  the  body.  It  is  in  all  parts  in- 
timately adherent,  by  means  of  the  subcutaneous 
tissue,  to  the  aponeurosis  and  muscle  beneath  it, 
and,  from  this  adhesion,  it  follows  that  the  skin 
moves  in  all  movements  of  that  muscle.  The  sub- 
cutaneous tissue  is,  like  a  similar  tissue  in  the 
palm,  admirably  constructed  to  resist  pressure, 
being  composed  of  a  multitude  of  fibrous  bands 
enclosing  fat  lobules  in  more  or  less  isolated  spaces 
(Fig.  1,  b).  ^  The  density  of  the  scalp  is  such,  that 
in  surface  inflammations,  such  as  cutaneous  ery- 
sipelas, it  is  unable  to  present  (except  in  a  very 
slight  degree)  two  conspicuous  features  of  such 
inflammations,  viz.  redness  and  swelling.  The  skin 

B 


THE    HEAD    AND    NECK 


[Chap. 


is  provided  with  a  great  number  of  sebaceous 
glands,  which  may  develop  into  cystic  tumours  or 
wens,  such  cysts  being  more  common  upon  the  scalp 
than  in  any  other  part  of  the  body.  Being  skin 
growths,  these  cysts,  even  when  large,  remain,  ex- 


— C6 

— h 
c 

■ — a 

■--/ 

—3 
— k 


-Diagram  showing    the    layers    of   the    scalp   and 
membranes  of  the  brain  in  section. 

a,  Skin  ;  b,  subcutaneous  tissue  with  hair  roots  and  vessels  :  <\  epi- 
cranium ;  d,  subaponeurotic  layer ;  c,  pericranium  ;  /,  parietal 
bone;  g,  dura  mater;  A-,  arachnoid;  Z,  pia  mater;  m,  cortex  ; 
w,  in  subdural  space  near  a  Pacchionian  body  projecting  within 
the  superior  longitudinal  sinus, 


cept  in  rare  instances,  entirely  outside  the  apo- 
neurosis, and  can  therefore  be  removed  without 
risk  of  opening  up  the  area  of  loose  connective 
tissue  between  the  aponeurosis  and  the  peri- 
cranium. 

There  being  no  fatty  tissue  in  any  of  the  layers 


I]  THE    SCALP  3 

that  cover  the  bony  vault  save  in  the  subcutaneous 
layer,  it  happens  that  in  cases  of  obesity  the  scalp 
undergoes  but  little  change,  the  fat  in  the  subcu- 
taneous tissue  being  limited  by  the  dense  fibrous 
structures  that  enclose  it.  For  the  same  reasons 
fatty  tumours  of  the  scalp  are  very  rare.  The 
attachment  of  the  hairs  collectively  to  the  scalp 
is  so  strong  that  there  are  many  cases  where  the 
entire  weight  of  the  body  has  been  supported  by 
the  hair  of  the  scalp.  Agnew  records  the  case  of 
a  woman  whose  hair  became  entangled  in  the  re- 
volving shaft  of  a  machine.  The  hair  did  not  give 
way,  but  the  entire  scalp  was  torn  off  from  the 
skull.     The  patient  recovered. 

Dangerous  area  of  the  scalp.  —  Between 
the  aponeurosis  and  the  pericranium  is  an  exten- 
sive layer  of  loose  connective  tissue,  that  may,  for 
reasons  to  be  presently  given,  be  fairly  called  the 
dangerous  area  of  the  scalp  (Fig.  1,  d).  The 
mobility  of  the  scalp  depends  entirely  upon  the 
laxity  of  this  layer  of  tissue.  In  extensive  scalp 
wounds,  when  a  part  of  the  scalp  is  separated  in 
the  form  of  a  large  flap,  a  flap  that  may  hang 
down  and  cover  half  the  face,  it  is  the  very  loose- 
ness of  this  tissue  that  permits  such  separation. 
In  the  Indian  process  of  scalping,  a  taste  that  is 
becoming  one  of  the  past,  the  much-prized  piece 
of  skin  is  torn  from  the  skull  through  this  lax 
area  of  connective  tissue,  and,  were  there  no  such 
area,  scalping  would  be  an  operation  requiring 
some  time  and  art. 

The  exposure  of  the  skull  in  a  post-mortem 
examination  is  effected  by  peeling  off  the  scalp 
along  this  layer  of  loose  tissue,  and  it  is  remark- 
able with  what  ease  the-  skull  can  be  exposed  by 
this  manoeuvre. 

Wounds  of  the  scalp  never  gape,  unless  the 
wound  has  involved  the  scalp  muscle  or  its  apo- 
neurosis. When  this  structure  has  been  divided 
the  lax  layer  beyond  permits  of  great  separation  of 
the  edgesof  even  the  simplest  wounds.  In  uncom- 
plicated incised  wounds,  the  amount  of  gaping  of 


I  THE    HEAD    AND    NECK  [Chap. 

the  cut  depends  upon  the  action  of  the  occipito- 
frontal muscle.  Those  wounds  gape  the  most 
that  are  made  across  the  muscle  itself,  and  that 
are  transverse  to  the  direction  of  its  fibres,  while 
those  show  the  least  separation  that  involve  the 
aponeurosis  and  are  made  in  an  antero-posterior 
direction.  The  mobility  of  the  scalp  is  more 
marked  in  the  young  tiian  in  the  old.  A  case 
recorded  by  Agnew  serves  in  a  strange  degree  to 
illustrate  this  fact  in  the  person  of  an  infant.  A 
midwife  attending  a  woman  in  labour  mistook 
the  scalp  of  the  infant  for  the  membranes,  and 
gashed  it  with  a  pair  of  scissors.  Labour  pains 
came  on  and  the  head  was  protruded  through  the 
scalp  wound,  so  that  the  whole  vault  of  the  skull 
was  peeled  like  an  orange.  The  scalp  being  firmly 
stretched  over  the  hard  cranium  beneath,  it  follows 
that  contused  wounds  often  appear  as  cleanly  cut 
as  are  those  that  have  been  made  by  an  incision. 
Such  wounds  may  be  compared  to  the  clean  cut 
that  may  be  made  in  a  kid  glove  when  it  is  tightly 
stretched  over  the  knuckles  and  those  parts  are 
sharply  rapped. 

The  scalp  is  extremely  vascular,  and  presents 
therefore  a  great  resistance  to  sloughing  and  gan- 
grenous conditions.  Large  flaps  of  a  lacerated 
scalp,  even  when  extensively  separated  and  almost 
cut  off  from  the  rest  of  the  iiead,  are  more  prone 
to  live  than  to  die.  A  like  flap  of  skin,  separated 
from  other  parts  of  the  surface,  would  most  prob- 
ably perish ;  but  the  scalp  has  this  advantage,  that 
the  vessels  run  practically  in  the  skin  itself,  or 
are,  at  least,  in  the  tissue  beyond  the  aponeurosis 
(Fig.  1).  Thus,  when  a  scalp  flap  is  torn  up,  it 
still  carries  with  it  a  very  copious  blood  supply. 
Bleeding  from  these  wounds  is  usually  very  free, 
and  often  difficult  to  arrest.  This  depends  not 
so  much  upon  the  number  of  vessels  in  the  part  as 
upon  the  density  of  the  tissue  through  which  these 
vessels  run,  the  *  adherence  of  the  outer  arterial 
wall  to  the  scalp  structure,  and  the  inability, 
therefore,  of  the  artery  to  retract  properly  when 


I]  THE    PERICRANIUM  5 

divided.  For  the  same  reason  it  is  almost  im- 
possible to  pick  up  an  artery  divided  in  a  scalp 
wound.  The  bleeding  is  checked  by  a  hare-lip 
pin  or  by   pressure. 

In  all  parts  of  the  body  where  a  dense  bone  is 
covered  by  a  comparatively  thin  layer  of  soft  tis- 
sues, sloughing  of  those  tissues  is  apt  to  be  in- 
duced by  long  and  severe  pressure.  The  scalp,  by 
its  vascularity,  is  saved  to  a  great  extent  from 
this  evil,  and  is  much  less  liable  to  slough  than 
are  the  soft  parts  covering  such  bones  as  the  con- 
dyles of  the  humerus  or  the  sacrum.  But  such  an 
effect  is  sometimes  produced,  as  in  a  case  I  saw, 
where  the  tissues  over  the  frontal  and  occipital 
regions  sloughed  from  the  continued  application 
of  a  tight  bandage  put  on  to  arrest  bleeding  from 
a  frontal  wound. 

The  pericranium  is  but  slightly  adherent  to 
the  bone,  except  at  the  sutures,  where  it  is  inti- 
mately united  (Fig.  1,  e).  In  lacerated  wounds 
this  membrane  can  be  readily  stripped  from  the 
skull,  and  often,  in  these  injuries,  extensive  tracts 
of  bone  are  laid  bare.  The  pericranium  differs 
somewhat  in  its  functions  from  the  periosteum 
that  covers  other  bones.  If  the  periosteum  be 
removed  to  any  extent  from  a  bone,  the  part  from 
whence  it  is  removed  will  veryo  probably  perish, 
and  necrosis  from  deficient  blood  supply  result. 
But  the  pericranium  may  be  stripped  off  a  con- 
siderable part  of  the  skull  vault  without  any 
necrosis,  save  perhaps  a  ^little  superficial  ex- 
foliation. This  is  explained  by  the  fact  that 
the  cranial  bones  derive  their  blood  supply 
mainly  from  the  dura  mater,  and  are  therefore 
to  a  considerable  extent  independent  of  the 
pericranium.  A  like  independence  cannot  be 
claimed  for  the  periosteum  covering  other  bones, 
since  that  membrane  brings  to  the  part  it  covers 
a  very  copious  and  essential  contribution  to  its 
blood  supply.  This  disposition  of  the  pericran- 
ium is  also  well  illustrated  by  its  action  in  cases 
of  necrosis  of  the  cranial  bones.     In  necrosis  of  a 


6  THE    HEAD    AND    NECK  [Chap. 

long  bone,  the  separation  of  the  sequestrum  is 
attended  with  a  vigorous  periosteal  growth  of 
new  bone,  which  repairs  the  gap  left  after  the  re- 
moval of  such  sequestra.  In  necrosis  of  the  vault 
of  the  skull,  however,  no  new  bone  is  formed,  as 
a  rule,  and  the  gap  remains  unrepaired.  The 
general  indisposition  of  the  pericranium  to  form 
new  bone  in  other  circumstances  is  frequently 
illustrated. 

Abscesses  in  the  scalp  region  may  be  situated 
(1)  above  the  aponeurosis,  (2)  between  the  apo- 
neurosis and  the  pericranium,  and  (3)  beneath  the 
pericranium.  Abscesses  in  the  first  situation  must 
always  be  small  and  comparatively  insignificant, 
since  the  density  of  the  scalp  tissue  here  is 
such  that  suppuration  can  only  extend  with  the 
greatest  difficulty.  Suppuration,  however,  in  the 
second  situation  (in  the  loose  tissue  beneath  the 
aponeurosis)  may  prove  very  serious.  The  laxity 
of  this  tissue  offers  every  inducement  to  the  ab- 
scess to  extend  when  once  pus  has  found  its  way 
between  the  aponeurosis  and  the  pericranium. 
Suppuration  in  this  area  may  undermine  the  en- 
tire scalp,  which  in  severe  and  unrelieved  cases 
may  rest  upon  the  abscess  beneath  as  upon  a  kind 
of  water-bed.  As  in  scalp  wounds,  the  aponeu- 
rosis is  often  divided,  and  as  suppuration  may 
follow  the  injury,  it  will  be  seen  that  the  chief 
danger  of  those  lesions  depends  upon  the  spread- 
ing of  such  suppuration  to  the  area  of  lax  con- 
nective tissue  now  under  notice.  _  The  significance 
of  a  small  amount  of  bare  bone  in  a  scalp  wound 
is  not  so  much  that  evils  will  happen  to  the  bone, 
but  that  the  aponeurosis  has  been  certainly 
divided,  and  the  dangerous  area  of  the  scalp 
opened  up.  Suppuration,  when  it  occurs  in  this 
area,  is  only  limited  by  the  attachments  of  the 
occipito-frontalis  muscle  and  its  aponeurosis,  and 
therefore  the  most  dependent  places  through  which 
pus  can  be  evacuated  are  situated  along  a  line 
drawn  round  the  head,  commencing  in  front,  above 
the  eyebrow,  passing  at  the  side  a  little  above  the 


II  ELEMATOMATA    OF    THE    SCALP  7 

zygoma,  and  ending  behind  at  the  superior  curved 
line  of  the  occipital  bone.  The  scalp,  even  when 
extensively  dissected  up  by  such  abscesses,  does 
not  perish,  since  it  carries,  as  above  explained,  its 
blood  supply  with  it.  The  abscess  is  often  very 
slow  to  close,  since  its  walls  are  prevented  from 
obtaining  perfect  rest  by  the  frequent  movement 
of  the  epicranial  muscle.  To  mitigate  this  evil, 
and  to  ensure  closing  of  the  sinuses  in  obstinate 
cases,  Mr.  Hilton  advises  that  the  whole  scalp  be 
firmly  secured  by  strapping,  so  that  the  movement 
of  the  muscle  is  arrested. 

Abscesses  beneath  the  pericranium  must  be 
limited  to  one  bone,  since  the  dipping-in  of  the 
membrane  at  the  sutures  prevents  a  more  exten- 
sive spreading  of  the  suppuration. 

Ilseniatomata,  or  blood  tumours,  of  the 
scalp  region  occur  in  the  same  localities  as  ab- 
scesses. The  extravasation  of  blood  above  the  apo- 
neurosis must  be  of  a  limited  character,  while  that 
beneath  it  may  be  very  extensive.  It  fortunately 
happens,  however,  that  the  cellular  tissue  between 
the  aponeurosis  and  the  pericranium  contains  but 
very  few  vessels,  and  hence  large  extravasations  in 
this  tissue  are  uncommon. 

Extravasations  of  blood  beneath  the  peri- 
cranium are  generally  termed  cephalhsematomata, 
and  are  of  necessity  limited  to  one  bone.  They 
are  usually  congenital,  are  due  to  pressure  upon 
the  head  at  birth,  and  are  thus  most  commonly 
found  over  one  parietal  bone,  that  bone  being 
probably  the  one  most  exposed  to  pressure.  Their 
greater  frequency  in  male  children  may  depend 
upon  the  larger  size  of  the  head  in  the  male  foetus. 
Such  extravasations  in  early  life  are  encouraged 
by  the  laxity  of  the  pericranium,  and  by  the  soft- 
ness and  vascularity  of  the  subjacent  bone. 

In  the  temporal  region,  or  the  region  corre- 
sponding to  the  temporal  muscle,  the  layers  of  soft 
parts  between  the  skin  and  the  bone  are  some- 
what different  from  those  that  have  been  already 
described  as  common  to  the  chief  parts  of  the  scalp. 


8  THE    HEAD    AND    NECK  [Chap. 

There  is  a  good  deal  of  fat  in  the  temporal  fossa, 
and  when  this  is  absorbed  it  leads  to  more  or  less 
prominence  of  the  zygoma  and  malar  bone,  and 
so  produces  the  projecting  "cheek  bones "  of  the 
emaciated.  The  temporal  muscle  above  the  zy- 
goma is  covered  in  by  a  very  dense  fascia,  the 
temporal  fascia,  which  is  attached  above  to  the 
temporal  ridge  on  the  frontal  and  parietal  bones, 
and  below  to  the  zygomatic  arch.  The  unyielding 
nature  of  this  fascia  is  well  illustrated  by  a 
case  recorded  by  Denonvilliers.  It  concerned  a 
woman  who  had  fallen  in  the  street,  and  was  ad- 
mitted into  hospital  with  a  deep  wound  in  the 
temporal  region.  A  piece  of  bone  of  several  lines 
in  length  was  found  loose  at  the  bottom  of  the 
wound,  and  was  removed.  After  its  removal  the 
finger  could  be  passed  through  an  opening  with 
an  unyielding  border,  and  came  in  contact  with 
some  soft  substance  beyond.  The  case  was  con- 
sidered to  be  one  of  compound  fracture  of  the 
squamous  bone,  with  separation  of  a  fragment 
and  exposure  of  the  brain.  A  bystander,  however, 
noticed  that  the  bone  removed  was  dry  and  white, 
and  a  more  complete  examination  of  the  wound 
revealed  the  fact  that  the  skull  was  uninjured, 
that  the  supposed  hole  in  the  skull  was  merely 
a  laceration  of  the  temporal  fascia,  that  the  soft 
matter  beyond  was  muscle  and  not  brain,  and  that 
the  fragment  removed  was  simply  a  piece  of  bone 
which,  lying  on  the  ground,  had  been  driven  into 
the  soft  parts  when  the  woman  fell. 

Abscesses  in  the  temporal  fossa  are  prevented 
by  the  fascia  from  opening  anywhere  above  the 
zygoma,  and  are  encouraged  rather  to  spread  into 
the  pterygoid  and  maxillary  regions  and  into  the  neck. 

The  pericranium  in  the  temporal  region  is 
much  more  adherent  to  the  bone  than  it  is  over 
the  rest  of  the  vault,  and  subpericranial  extrava- 
sations of  blood  are  therefore  practically  unknown 
in  this  part  of  the  cranial  wall. 

Trephining-. — This  operation  is  frequently  per- 
formed in  the  temporal  region,   its  object  being 


I]  TREPHINING  9 

to  reach  extravasations  of  blood  from  the  middle 
meningeal  artery.  This  artery  crosses  the  an- 
terior inferior  angle  of  the  parietal  bone  at  a 
point  1^  inches  behind  the  external  angular  pro- 
cess of  the  frontal  bone,  and  lj  inches  above  the 
zygoma.  In  cutting  down  to  expose  this  artery 
tne  following  structures  are  met  with  in  order  : 
(1)  The  skin;  (2)  branches  of  the  superficial  tem- 


E>R.cqMA 


SUP.TEM.LlrtE 

Lambda 
Squamous  Suture] 


POST.DlV.OFrtlD.AlEfl.AR1 

asteriom 
Supra  /IeatalTriaacle 
Lateral  Sinus 

Imori 
Ext.  Auditory  -Meatus 
Occipital  Ar.t 


.Coronal  suture 


Pronto  Malar 
Suture 


ArtT  Div  op 
Mid. Mem.  Art. 


Mid  Mem.  Art. 
!ait.  Max  Art 


Imt.  Juqular  Veim 


Ext.  Carotid  Art. 


Fig.  2.  -Points  to  trephine  for  middle  meningeal  artery  and 
lateral  sinus. 


poral  vessels  and  nerves ;  (3)  the  fascia  continued 
down  from  the  epicranial  aponeurosis;  (4)  the 
temporal  fascia ;  (5)  the  temporal  muscle ;  (6)  the 
deep  temporal  vessels;  (7)  the  pericranium;  (8) 
the  anterior  inferior  angle  of  the  parietal  bone. 

Trephining  for  meningeal  haemorrhage  and 
cerebral  abscess. — At  the  anterior  inferior  angle 
of  the  parietal  bone  the  anterior  division  of  the 
middle  meningeal  artery  lies  with  its  companion 
veins  in  a  deep  groove  or  even  canal  in  the  bone. 


10  THE    HEAD    AND    NECK  [Chap. 

A  fracture  of  the  bone,  which  is  comparatively 
thin  in  the  region  of  the  pterion,  is  apt  to  involve 
the  artery,  leading  to  a  subdural  haemorrhage, 
with  consequent  compression  of  the  brain.  The 
pterion  lies  lj  inches  behind  and  h  an  inch  above 
the  notch  of  the  fronto-malar  suture — a  point 
which  can  be  readily  felt  (Fig.  2).  Similar  mea- 
surements— namely,  li  inches  behind  and  \  an  inch 
above — taken  from  the  centre  of  the  external 
auditory  meatus — the  meatal  point,  give  the  posi- 
tion of  the  posterior  inferior  angle  of  the  parietal 
bone  (asterion),  beneath  which  lies  the  highest 
point  of  the  lateral  sinus  (Fig.  2).  A  trephine 
opening,  }  of  an  inch  in  diameter,  made  over  the 
asterion,  will  expose  the  lateral  sinus,  and  give 
access  to  the  temporo-sphenoidal  lobe  above  it 
and  to  the  cerebellum  below  it.  >  The  posterior 
division  of  the  middle  meningeal,  in  the  majority 
of  cases,  will  be  exposed  by  trephining  at  a  point 
1  inch  above  the  external  auditory  meatus.  These 
measurements  apply  to  the  head  of  the  average 
adult;  allowance  must  be  made  for  youth  and 
for  the  size  and  shape  of  the  head.  In  finding 
pterion,  a  line  is  drawn  backwards  parallel  to 
the  upper  border  of  the  zygoma;  in  finding  as- 
terion^ a  line^  is  drawn  backwards  along  the 
meato-inionic  line  (Fig.  2),  which  passes  from  the 
centre  of  the  external  meatus  to  the  most  promi- 
nent point  of  the  external  occipital  protuberance 
— the  inion. 

Intracranial  abscess  is  often  due  to  middle-ear 
disease,  and  is  then  very  commonly  found  in  the 
temporo-sphenoidal  lobe  or  in  the  cerebellum.  It 
is  estimated  to  be  three  times  more  common  in 
the  cerebrum  than  in  the  cerebellum. 

The  abscess  of  the  temporo-sphenoidal  lobe  is 
usually  found  in  that  part  of  the  lobe  which  lies 
over  the  tegmen  tympani — a  thin  plate  of  bone 
which  forms  the  roof  of  the  tympanum  and  of  the 
antrum  of  the  mastoid.  The  level  of  the  tegmen 
may  be  indicated  thus  (Fig.  3)  :  a  point  is  taken 
above  the  meatus  in  line  with  the  upper  border  of 


IJ  TREPHINING  11 

the  zygoma;  this  suprameatal  point  is  joined 
with  the  asterion,  which  lies,  it  will  be  remem- 
bered, lj  inches  behind  and  i  an  inch  above  the 
meatus ;  the  anterior  half  of  the  above  line  corre- 
sponds to  the  tegmen  tympani.  A  trephine  open- 
ing made  1  inch  above  the  level  of  the  tegmen  is 
the  most  likely  to  give  access  to  a  temporo- 
sphenoidal  abscess. 

In  dealing  with  an  abscess  of  the  cerebellum 
the  best  spot  to  select  is,  in  the  adult,  l\  inches 
behind  the  centre  of  the  meatus  and  J  of  an  inch 
below  the  meato-inionic   line. 

In  some  cases  it  is  impossible  to  say  whether  the 
abscess  is  situated  in  the  temporo-sphenoidal  lobe 
or  cerebellum.  In  such  cases  Mr.  Dean  trephines  at 
a  point  which  lies  lj  inches  behind  and  \  of  an  inch 
above  the  centre  of  the  meatus.  The  lateral  sinus 
is  thus  exposed  with  a  part  of  the  dura  mater 
above  the  tentorium  cerebelli,  through  which  the 
temporo-sphenoidal  lobe  may  be  explored.  By  ex- 
tending the  trephine  opening  \  an  inch  downwards 
the  cerebellum  may  be  examined. 

Trephining  for  cerebral  tumour. — The  position 
of  the  opening  in  the  skull  is  obviously  determined 
by  the  localizing  symptoms.  It  is  remarkable  that 
little  trouble  from  haemorrhage  has  attended  these 
operations. 

In  any  case,  after  trephining,  the  portion  or 
portions  of  bone  removed  may— if  properly 
treated — be  replaced  in  the  opening,  and  will 
serve,  especially  in  youthful  subjects,  to  make 
good  the  gap  left  by  the  operation.  The  osteo- 
blasts in  the  fragments  remain  alive  and  retain 
the  power  of  bone-formation. 

In  trephining  the  skull,  the  comparative  thick- 
ness of  the  cranial  wall  in  various  parts  should 
be  borne  in  mind,  and  the  large  arteries  of  the 
scalp  should  be  avoided  if  possible.  In  order 
to#  accommodate  the  instrument  to  the  varying 
thickness  of  the  skull,  the  pin  of  the  trephine 
is  not  allowed  to  protrude  more  than  Ath  of 
an  inch. 


12 


THE    HEAD    AND    NECK 


[Chap. 


The  zygoma  may  be  broken  by  direct  or  in- 
direct violence.  In  the  latter  case  the  violence  is 
such  as  tends  to  thrust  the  upper  jaw  or  malar 
bone  backwards.  When  due  to  direct  violence,  a 
fragment  may  be  driven  into  the  temporal  muscle, 
and  much  pain  caused  in  moving  the  jaw.  In 
ordinary  cases  there  is  little  or  no  displacement, 
since  to  both  fragments  the  temporal  fascia  is 
attached  above  and  the  masseter  below.  The  zy- 
goma serves  as  a  most  useful  guide  to  the  position 


Frontal  Pole. 

Anterior  flOR/1 

fiSSUREorSVLVIUS! 

PtERION 

IslamdofReil^ 

FRONTO/lALAR 

Suture 

Temporal    ' 
Pole- 


Upper  Rolandic  Point 


Fissure  of  Rolando 


Parietal  Eminence 

Parieto  Occipital  Fissure- 
Lambda 

For  Lateral  Ventricle- 
Post.  Morn 

DESC.AfORfl 

for  Tenp.-Spnen.  Abscess 


Cerebellum 

Asterion 
T>m panic  Plate 
Suprameatal  Triangle 
Meatus 
Suprameatal  Point  , 


Fig.  3. 


-Diagram  to  show  the  position  of  the  lateral  ven- 
tricles, island  of  Reil,  and  temporal  pole. 


of  deep  parts.  Its  upper  border,  in  its  posterior 
three-fourths,  corresponds  to  the  floor  of  the  mid- 
dle fossa  of  the  skull,  and  marks  the  lower  border 
of  the  temporal  lobe  of  the  brain  which  lies  in 
that  fossa  (Fig.  3) ;  the  articular  eminence,  felt 
so  plainly  near  its  root,  marks  the  point  at  which 
the  middle  meningeal  artery  perforates  the  base 
of  the  skull  by  the  foramen  spinosum  (Fig.  2), 
and  also  the  position  of  the  Gasserian  ganglion 
(Fig.  30,  p.  125);  the  post-glenoid  spine  is  directly 
over  the  carotid  canal  (S.   Scott). 


I]       ARTERIES    AND    VEINS    OF    THE    SCALP     13 

Vessels  and  nerves  of  the  scalp.— The 
supraorbital  artery  and  nerve  pass  vertically  up- 
wards from  the  supraorbital  notch,  which  is  situ- 
ate at  the  junction  of  the  middle  with  the  inner 
third  of  the  upper  orbital  margin.  Nearer  the 
middle  line  the  frontal  artery  and  supratrochlear 
nerve  ascend.  This  artery  gives  life  to  the  flap 
that  in  rhinoplasty  is  taken  from  the  forehead 
to  form  a  new  nose.  The  temporal  artery,  with 
the  auriculo-temporal  nerve  behind  it,  crosses  the 
base  of  the  zygoma  just  in  front  of  the  ear.  The 
vessel  divides  into  its  two  terminal  branches  (the 
anterior  and  posterior)  2  inches  above  the  zygoma. 
The  branches  of  this  artery,  especially  the  an- 
terior branch,  are  often  very  tortuous  in  the  aged, 
and  afford  early  evidence  of  arterial  degeneration. 
Arteriotomy  is  sometimes  practised  on  the  an- 
terior branch  of  this  vessel.  The  superficial  tem- 
poral vessels  are  very  liable  to  be  the  seat  of 
cirsoid  aneurysm,  as,  to  a  less  extent,  are  the  other 
scalp  arteries.  The  posterior  auricular  artery  and 
nerve  run  in  the  groove  between  the  mastoid 
process  and  the  ear,  and  the  occipital  artery  and 
the  great  occipital  nerve  reach  the  scalp  just 
internally  to  a  point  midway  between  the  occi- 
pital protuberance  and  the  mastoid  process. 

Certain  of  the  emissary  veins  are  of  import- 
ance in  surgery.  t  These  veins  pass  through  aper- 
tures in  the  cranial  wall,  and  establish  communi- 
cations between  the  venous  circulation  (the 
sinuses)  within  the  skull  and  the  superficial  veins 
external  to  it.  The  principal  emissary  veins  are 
the  following  :  1.  A  vein  passing  through  the  mas- 
toid foramen  and  connecting  the  lateral  sinus 
with  the  posterior  auricular  vein  or  with  an  occi- 
pital vein.  This  is  the  largest  and  most  constant 
of  the  series.  The  existence  of  this  mastoid  vein 
serves  to  answer  the  question,  Why  is  it  a  com- 
mon practice  to  apply  leeches  and  blisters  behind 
the  ear  in  certain  cerebral  affections?  2.  A  vein 
connecting  the  superior  longitudinal  sinus  with 
the  veins  of  the  scalp  through  the  parietal  foramen. 


14  THE    HEAD    AND    NECK  [Chap. 

'3.  A  vein  connecting  the  lateral  sinus  with  the 
deep  veins  at  the  back  of  the  neck  through  the 
posterior  condylar  foramen  (inconstant).  4. 
Minute  veins  following  the  twelfth  nerve  through 
its  foramen,  and  connecting  the  occipital  sinus 
with  the  deep  veins  of  the  neck.  5.  Minute  veins 
passing  through  the  foramen  ovale,  foramen  of 
Vesalius,  foramen  lacerum  medium,  and  carotid 
canal  to  connect  the  cavernous  sinus  with  (respec- 
tively) the  pterygoid  venous  plexus,  the  pharyn- 
geal plexus,  and  the  internal  jugular  vein. 

Then,  again,  many  minute  veins  connect  the 
veins  of  the  scalp  with  those  of  the  diploe.  Of  the 
four  diploic  veins,  two  (the  frontal  and  anterior 
temporal)  enter  into  surface  veins  (the  supra- 
orbital and  deep  temporal),  and  two  (the  pos- 
terior temporal  and  occipital)  enter  into  the 
lateral  sinus. 

Lastly,  there  is  the  well-known  communication 
between  the  extra-  and  intracranial  venous  circu- 
lation effected  by  the  commencement  of  the  facial 
vein  at  the  inner  angle  of  the  orbit.  In  this  com- 
munication the  angular  and  supraorbital  veins 
unite  with  the  superior  ophthalmic  vein,  a  tribu- 
tary of  the  cavernous  sinus.  The  veins  within  the 
cavities  of  the  nose  and  middle  ear  also  communi- 
cate with  those  of  the  meninges. 

Through  these  various  channels,  and  through 
many  probably  still  less  conspicuous,  inflammatory 
processes  can  spread  from  the  surface  to  the  in- 
terior of  the  skull.  Thus  we  find  such  affections  as 
erysipelas  of  the  scalp,  diffuse  suppuration  of  the 
scalp,  necrosis  of  the  cranial^  bones,  and  the  like, 
leading  by  extension  to  mischief  within  the  diploe, 
to  thrombosis  of  the  sinuses,  and  to  inflammation 
of  the  meninges  of  the  brain.  If  there  were  no 
emissary  veins,  injuries  and  diseases  of  the  scalp 
and  skull  would  lose  half  their  seriousness.  Mis- 
chief may  even  spread  from  within  outwards  along 
an  emissary  vein.  Erichsen  reports  a  case  where 
the  lateral  sinus  was  exposed  in  a  compound  frac- 
ture.   The  aperture  was  plugged.    Thrombosis  and 


I] 


VENOUS    TUMOURS    OF    THE    SKULL 


15 


suppuration  within  the  sinus  followed,  and  some  of 
the  pus,  escaping  through  the  mastoid  vein,  led  to 
an  abscess  in  the  neck. 


Fig.  4. — Nerve  areas  of  the  face  and  scalp. 

A,  A,  Distribution  of  the  first  division  of  the  fifth  cranial  nerve :  A', 

nasal  branch  ;  A",  supratrochlear ;  A'",  supraorbital. 

B,  B,  Distribution  of  the  second  division :  B',  infraorbital  branch  ; 

B",  malar  branch  ;  B'",  temporal  branch. 

C,  c,  Distribution  of  third  division :  c\  mental  branch :  c",  buccal 

branch ;  C"',  auriculo-temporal. 
1,  Area  of  great  occipital ;  2,  of  small  occipital :  3,  of  great  auricular  ; 
4,  of  superficial  cervical ;  5 ,  of  third  occipital. 

Certain  venous  tumours  are  met  with  on  the 
skull.  They  consist  of  collections  of  venous  blood 
under  the  pericranium  that  communicate,  through 


16  THE    HEAD    AND    NECK  [Chap.  I 

holes  in  the  skull,  with  the  superior  longitudinal 
sinus.  They  are  median,  are  reducible  on  pressure, 
and  receive  a  faint  pulsation  from  the  brain.  The 
holes  are  sometimes  the  result  of  accident,  others 
depend  upon  bone  disease  or  atrophy  over  a  Pac- 
chionian body,  and  a  few  are  due  to  a  varicose 
emissary  vein  or  to  a  congenital  defect  in  the 
cranium,  especially  in  the  neighbourhood  of  the 
parietal  foramina. 

The  scalp  nerves,  especially  such  as  are  branches 
of  the  fifth  pair,  are  often  the  seat  of  neuralgia 
(Fig.  4).  To  relieve  one  form  of  this  affection,  the 
supraorbital  nerve  has  been  divided  (neurotomy), 
or  paralysed  by  an  injection  of  absolute  alcohol 
at  its  point  of  exit  from  the  orbit.  Some  forms 
of  frontal  headache  depend  upon  neuralgia  of 
this  nerve.  The  inner  branch  of  the  nerve 
reaches  the  middle  of  the  parietal  bone;  the  outer 
branch,   the  lambdoid  suture. 

The  lymphatics  from  the  occipital  and  posterior 
parietal  regions  of  the  scalp  enter  the  occipi- 
tal and  mastoid  glands;  those  from  the  frontal 
and  anterior  parietal  regions  go  to  the  parotid 
glands,  while  some  of  the  vessels  from  the  frontal 
region  join  the  lymphatics  of  the  face  and  end  in 
the  submaxillary  glands  (Fig.   44,   p.   197). 


CHAPTER    II 

THE    BONY   VAULT    OF   THE    CRANIUM 

Position  of  the  sutures.  —  The  bregma,  or 
point  of  junction  of  the  coronal  and  sagittal 
sutures,  is  in  a  line  drawn  vertically  upwards  from 
a  point  just  in  front  of  the  external  auditory 
meatus,  the  head  being  in  normal  position  (Fig.  2). 
The  lambda,  or  point  of  junction  of  the  lambdoid 
and  sagittal  sutures,  lies  in  the  middle  line,  about 
2^  inches  above  the  occipital  protuberance  (Fig.  2). 
The  lambdoid  suture  is  fairly  represented  by  the 
upper  two-thirds  of  a  line  drawn  from  the  lambda 
to  the  apex  of  the  mastoid  process  on  either  side. 
The  coronal  suture  lies  along  a  line  drawn  from 
the  bregma  to  the  middle  of  the  zygomatic  arch. 
On  this  line,  at  a  spot  about  li  inches  behind  and 
4  an  inch  above  the  fronto-malar  junction,  is 
the  pterion,  the  region  where  four  bones  meet, 
viz.  the  squamous  bone,  the  great  wing  of  the 
sphenoid,  the  frontal  and  parietal  bones  (Fig.  2). 
The  summit  of  the  squamous  suture  is  If  inches 
above  the  zygoma. 

In  the  normal  subject  all  traces  of  the  fon- 
tanelles  and  other  unossified  parts  of  the  skull 
disappear  before  the  age  of  two  years  (Fig.  6). 
The  anterior  fontanelle  is  the  last  to  close,  while 
the  posterior  is  already  filled  at  the  time  of 
birth.  It  is  through  or  about  the  anterior 
fontanelle  that  the  ventricles  are  usually  as- 
pirated in  cases  of  hydrocephalus.  The  needle 
is  either  entered  at  the  sides  of  the  fontanelle 
at  a  sufficient  distance  from  the  middle  line  to 
17 


18  THE    HEAD    AND    NECK  [Chap. 

avoid  the  longitudinal  sinus,  or  is  introduced 
through  the  coronal  suture  at  some  spot  other 
than  its  middle  point.  It  may  be  noted  that 
in  severe  hydrocephalus  the  coronal  and  other 
sutures  of  the  vault  are  widely  opened. 

The  condition  known  as  eranio-tafoes,  a  con- 
dition assigned  by  some  to  rickets  and  by  others  to 
inherited  syphilis,  is  usually  met  with  in  the  verti- 
cal part  of  the  occipital  bone,  and  in  the  adjacent 
parts  of  the  parietal  bones,  but  especially  in  the 
posterior  inferior  angles  of  these  bones.  In  this 
condition  the  bone  is  greatly  thinned  in  spots,  and 
its  tissue  so  reduced  that  the  affected  district  feels 
to  the  finger  as  if  occupied  by  parchment,  or,  as 
some  suggest,  by  cartridge  paper.  The  thinning  is 
mainly  at  the  expense  of  the  inner  table  and  diploe. 
The  pits  are  situated  over  the  impressions  of  early 
formed  convolutions.  It  is,  on  the  other  hand, 
about  the  site  of  the  anterior  fontanelle  that  cer- 
tain osseous  deposits  are  met  with  on  the  surface 
of  the  skull  in  some  cases  of  hereditary  syphilis 
(Parrot).  These  deposits  appear  as  rounded  ele- 
vations of  porous  bone  situated  upon  the  frontal 
and  parietal  bones,  where  they  meet  in  the  middle 
line.  ^  The  bosses  are  separated  by  a  crucial  de- 
pression represented  by  the  frontal  and  sagittal 
sutures  on  the  one  hand  and  the  coronal  suture  on 
the  other.  They  have  been  termed  "  natiform  " 
elevations  by  M.  Parrot  from  their  supposed  resem- 
blance, when  viewed  collectively,  to  the  nates.  To 
the  English  mind  they  would  rather  suggest  the 
outlines  of  a  "hot-cross  bun." 

It  is  necessary  to  refer  to  the  development  of 
the  skull  in  order  to  render  intelligible  certain 
conditions  (for  the  most  part  those  of  congenital 
malformation)  that  are  not  infrequently  met  with. 
Speaking  generally,  it  may  be  said  that  the  base  of 
the  skull  is  developed  in  cartilage,  and  the  vault 
in  membrane.  The  parts  actually  formed  in  mem- 
brane are  represented  in  the  completed  skull  by 
the  frontal  and  parietal  bones,  the  squamo-zygo- 
matic  part  of  the  temporal  bone,  and  the  greater 


II] 


MENINGOCELE 


19 


part  of  the  expanded  portion  of  the  occipital  bone. 
The  distinction  between  these  two  parts  of  the 
skull  is  often  rendered  very  marked  by  disease. 
Thus  there  are,  in  the  museum  of  the  Koyal  College 
of  Surgeons,  the  skulls  of  some  young  lions  that 
were  born  in  a  menagerie,  and  that,  in  consequence 
of  malnutrition,  developed  certain  changes  in 
their  bones.  A  great  part  of  each  of  these  skulls 
shows  considerable  thickening,  the  bone  being  con- 
verted into  a  porous  structure  ;  and  it  is  remark- 
able to  note  that  these  changes  are  limited  to  such 
parts  of  the  skull  as  are  formed  in  membrane,  the 
base  remaining  free.  In  hydrocephaly  and  in  the 
condition  known  as  achondroplasia,  it  is  only  the 
bones  formed  in  membrane  which  are  unduly  ex- 
panded. 

Among  the  more  common  of  the  gross  malforma- 
tions of  the  skull  also  is  one  that  shows  entire 
absence  of  all  that  part  pi  the  cranium  that  is 
formed  in  membrane,  while  the  base,  or  cartila- 
ginous part,  is  more  or  less  perfectly  developed — 
the  condition  of  anencephaly. 

Meningocele  is  the  name  given  to  a  con- 
genital tumour  that  consists  of  a  protrusion  of  a 
part  of  the  cerebral  mem- 
branes through  a  gap  in  an 
imperfectly  developed  skull. 
When  the#  protrusion  contains 
brain,  it  is  called  an  encepha- 
locele,  and  when  that  pro- 
truded brain ^  is  distended  by 
an  accumulation  of  fluid  with- 
in the  ventricles,  it  is  called 
hydrencephalocele.  These  pro- 
trusions are  most  often  met 
with  in  the  occipital  bone, 
and  next  in  frequency  in  the 
fronto-nasal  suture,  while  in 
rarer  cases  they  have  been 
met  with  in  the  lambdoid, 
sagittal,  and  other  sutures,  and  have  projected 
through    normal    and    abnormal    fissures    at    the 


Fig.   5. — The    occi- 
pital bone  at  birth. 


20 


THE    HEAT)    AND    NECK 


[Chap. 


base  of  the  skull  into  the  orbit,  nose,  and 
mouth.  Their  frequency  in  the  occipital  bone 
may  be  in  some  degree  explained  by  a  refer- 
ence to  the  development  of  that  part.  This 
bone  at  birth  consists  of  four  separate  parts 
(Fig.  5),  a  basilar,  two  condylar,  and  a  tabular 
or  expanded  part.  In  the  tabular  part,  about 
the  seventh  week  of  foetal  life  four  nuclei  appear, 
an  upper  and  a  lower  pair.  These  nuclei  are 
to  some  extent  separated  by  fissures  running 
inwards  from  the  four  angles  of  the  bone  to  meet 


T^ietopic  Suture 
..Frontal  Eminence 

_.BREqNATIC  fONTANELLE 

-.Coronal  suture 
..Saqittal  Suture 


Parietal  Eminence 
Sacittal  Tontanelle 

UrtBDOIDALrOMTA/tELLE 

Inter  Parietal 
Supra  Occipital 


Fig.  6. — Skull  of  newly  born  child,  from  above. 

at  the  occipital  protuberance.  The  gap  running 
up  in  the  median  line  from  the  inferior  angle  at 
the  foramen  magnum  to  the  occipital  protuberance 
is  especially  distinct  (the  temporary  occipital 
fontanelle  of  Sutton).  It  exists  from  the  beginning 
of  the  third  to  the  end  of  the  fourth  month  of 
intra-uterine  life.  Meningoceles  of  the  occiput 
are  always  in  the  middle  line,  and  the  protrusion 
probably  occurs  through  this  gap.  The  gap  associ- 
ated with  meningocele  may  extend  through  the 
whole  vertical  length  of  the  occipital  bone,  and 
very  commonly  opens  up  the  foramen  magnum. 
The  lateral  or  transverse  fissures  divide  the  bone 


Hj  FARIETAL    FISSURES  21 

into  two  parts.  The  upper  part  is  developed  from 
membrane,  the  lower  part  from  cartilage.  The 
lateral  fissures  may  persist,  and  may  simulate  frac- 
tures, for  which  they  have,  indeed,  been  mistaken  ; 
or  they  may  be  so  complete  as  entirely  to  separate 
the  highest  part  of  the  occipital  bone  from  the 
remainder.  The  bone  so  separated  is  the  05  epactal 
of  the  French,  the  interparietal  bone  of  some 
animals  (Fig.  6). 

Parietal  fissures. — In  the  developing  parie- 
tal bone,  fibres  concerned  in  ossification  radiate 
towards  the  periphery  from  two  nuclei  about  the 
centre  of  the  bone.  An  interfibrillar  space,  larger 
than  the  rest,  is  seen  about  the  fifth  month  to 
separate  the  loose  osseous  fibres  which  abut  on  the 
posterior  part  of  the  sagittal  border  from  the 
stronger  fibres  which  form  the  rest  of  this  border 
(Pozzi).  This  is  the  parietal  fissure  (Fig.  6).  It 
usually  closes  and  leaves  no  trace,  but  it  may  per- 
sist in  part  as  a  suture-like  fissure,  and  be  mistaken 
for  a  fracture.  If  the  fissure  persists  equally  on 
the  two  sides  an  elongated  lozenge-shaped  gap  is 
left,  the  sagittal  fontanelle  (Fig.  6).  It  is  situate 
about  an  inch  in  front  of  the  lambda,  and  occurs  in 
over  4  per  cent,  of  newly  born  children  (Lea).  The 
parietal  foramina  are  remains  of  this  interval. 

Wormian  bones. — These  irregular  bones 
may  be  mistaken  for  fragments  produced  by  frac- 
ture. They  are  most  usually  met  with  in  the  lamb- 
doid  suture.  One  Wormian  bone  deserves  special 
notice,  as  it  may  be  met  with  in  trephining  over 
the  middle  meningeal  artery.  It  exists  between  the 
anterior  inferior  angle  of  the  parietal  bone  and 
the  great  wing  of  the  sphenoid.  It  is  scale-like, 
and  gives  the  impression  that  the  tip  of  the  great 
wing  has  been  separated.  It  is  known  as  the 
epipteric  bone. 

Necrosis  is  fairly  common  on  the  vault  of 
the  skull,  and  most  often  attacks  the  frontal 
and  parietal  bones,  while,  for  reasons  that 
are  not  very  obvious,  it  is  rare  in  the  occi- 
pital   bone.        The    external    table    is    frequently 


22  THE    HEAD    AND    NECK  [Chap. 

necrosed  alone,  it  being  more  exposed  to  injury 
and  less  amply  supplied  with  blood  than  is 
the  internal  table.  From  the  converse  of  these 
reasons  it  happens  that  necrosis  of  the  internal 
table  alone  is  but  rarely  met  with.  Necrosis  in- 
volving the  entire  thickness  of  the  bone  may  prove 
very  extensive,  and  in  a  case  reported  by  Saviard, 
practically  the  whole  of  the  cranial  vault  necrosed 
and  came  away,.  The  patient  was  a  woman,  and 
the  primary  cause  of  the  mischief  was  a  fall  upon 
the  head  when  drunk. 

Necrosis  of  the  skull,  as  well  as  caries  of  the 
part,  is  attended  by  certain  special  dangers  that  de- 
pend upon  the  anatomical  relations  of  the  cranial 
bones.  Thus,  when  the  whole  thickness  of  the  skull 
is  involved  by  disease,  or  when  the  inner  table  is 
especially  attacked,  a  collection  of  pus  may  form 
between  the  dura  mater  and  the  affected  bone,  and 
may  produce  compression  of  the  brain.  When  the 
diploic  tissue  is  implicated,  the  veins  of  that  part 
may  become  thrombosed,  or  may  be  the  seat  of  a 
suppurative  phlebitis.  The  mischief  thus^  com- 
menced may  spread,  the  great  intracranial  sinuses 
may  be  closed  by  thrombus,  or  septic  matter  may 
be  conveyed  into  the  general  circulation  and  lead 
to  the  development  of  pyaemia. 

Mere  local  extension  may  also  cause  meningitis. 
In  cases  of  necrosis  of  the  external  table  the  growth 
of  granulation  tissue  from  the  exposed  and  vascu- 
lar diploe  ]Dlays  a  very  important  part  in  aiding 
the  exfoliation  of  the  lamella  of  dead  bone. 

Fractures  of  the  skull. — It  is  not  easy  ac- 
tually to  fracture  the  skull  of  a  young  infant.^  The 
skull  as  a  whole  at  this  age  is  imperfectly  ossified, 
the  sutures  are  wide,  and  between  the  bones  there 
is  much  cartilage  and  membrane.  Moreover,  the 
bones  themselves  in  early  life  are  elastic,  and  com- 
paratively soft  and  yielding.  If  a  blow  be  inflicted 
upon  the  vault  in  a  young  child  the  most  probable 
effect,  so  far  as  the  bone  itself  is  concerned,  is  an 
indenting  or  bulging-in  of  that  bone  unassqeiated 
with  a  fracture  in  the  ordinary  sense.   In  this  par- 


II]  FRACTURES    OF    THE    SKULL  23 

ticular  relation  the  skull  of  an  infant  is  to  that  of 
an  old  man  as  a  cranium  of  thin  tin  would  be  to  a 
cranium  of  strong  earthenware.  The  yielding  char- 
acter of  the  young  child's  skull  is  well  illustrated 
by  the  gross  deformity  of  the  head  that  certain 
Indian  tribes  produce  in  their  offspring  by  apply- 
ing tight  bandages  to  the  part  in  infancy.  In  the 
Royal  College  of  Surgeons  museum  are  many 
skulls  of  "  flat-headed  "  Indians,  that  show  to  what 
an  extreme  this  artificial  deformity  may  be  carried. 
Gueniot  also  asserts  that  much  deformity  of  the 
head  may  be  produced  in  infants  by  the  practice 
of  allowing  them  always  to  lie  upon  one  side  of 
the  body.  Here  the  deforming  agent  is  simply  the 
weight  of  the  brain. 

Even  in  adults  the  skull  is  much  less  brittle 
than  is  commonly  supposed,  and  notions  as  to  the 
breaking  ability  of  the  cranial  bones  derived  from 
the  study  of  the  dried  specimens  are  apt  to  be 
erroneous.  During  life  a  sharp  knife  properly 
directed  may  be  driven  through  the  cranial  vault  so 
as  to  cause  only  a  simple  perforating  wound  with- 
out splintering,  and  without  fracture  of  the  bone 
beyond  the  puncture.  Such  a  wound  may  be  as 
cleanly  cut  as  a  wound  through  thick  leather,  and 
a  specimen  in  the  London  Hospital  museum  serves 
well  to  illustrate  this.  A  case  reported  in  the 
Lancet  for  1881  affords  a  strange  instance  of  a  knife 
penetrating  the  skull  without  apparently  splinter- 
ing the  bone.  A  man  wishing  to  commit  suicide 
placed  the  point  of  a  dagger  against  the  skull  in 
the  upper  frontal  region,  and  then  drove  it  well 
into  the  brain  by  a  blow  from  a  mallet.  He  ex- 
pected to  fall  dead,  and  was  disappointed  to  find 
that  no  phenomena  of  interest  developed.  He  then 
drove  the  dagger  farther  in  by  some  dozen  blows 
with  the  mallet,  until  the  blade,  which  was  four 
inches  long,  was  brought  to  a  standstill.  The 
dagger  was  removed  with  great  difficulty,  the 
patient  never  lost  consciousness,  and  recovered 
without  a  symptom. 

The   following   anatomical   conditions  tend   to 


24  THE    HEAD    AND    NECK  [Chap 

minimize  the  effects  of  violence  as  applied  to  the 
skull  :  the  density  of  the  scalp  and  its  great 
mobility  ;  the  dome-like  arrangement  of  the  vault ; 
the  number  of  the  bones  that  compose  the  head, 
and  the  tendency  of  the  violence  to  be  broken  up 
amongst  the  many  segments  ;  the  sutures  which 
interrupt  the  continuity  of  any  given  force,  and  the 
sutural  membrane,  which  acts  as  a  kind  of  linear 
buffer  ;  the  mobility  of  the  head  upon  the  spine  ; 
and  the  elasticity  of  the  cranial  bones  themselves. 

The  skull  is  further  strengthened  by  the  pre- 
sence of  six  buttresses  or  pillars  at  the  junction  of 
the  vault  and  base.  Two  of  these  are  lateral,  the 
orbito-sphenoid  anteriorly  and  the  petro-mastoid 
posteriorly,  while  the  fronto-nasal  and  occipital 
strengthen  the  anterior  and  posterior  ends  of  the 
skull. 

In  children  the  membranous  layer  between  the 
sutures  is  of  considerable  thickness,  but  as  age 
advances  this  membrane  disappears  and  the  bones 
tend  to  fuse  together  (synostosis).  The  sutures 
begin  to  be  obliterated  about  the  age  of  40,  the 
change  commencing  on  the  inner  aspect  of  the 
suture,  and  appearing  first  in  the  sagittal  suture, 
then  in  the  coronal  and  lambdoid,  and  last  in 
the  squamous.  As  age  advances,  moreover,  the 
skull  bones  become  thicker  owing  to  a  deposit  over 
the  inner  table  to  replace  the  diminishing  brain, 
and  lose  much  of  their  elasticity.  They  are,  there- 
fore, more  readily  fractured  in  the  aged  than  in 
the  young. 

As  a  rule,  in  fracture,  the  entire  thickness  of  the 
bone  is  involved  ;  but  the  external  table  alone  may 
be  broken,  and  may  even  be  alone  depressed,  being 
driven  into  the  diploe,  or,  in  the  case  of  the  lower 
frontal  region,  into  the  frontal  sinus.  The  internal 
table  may  be  broken  without  a  corresponding  frac- 
ture in  the  outer  plate ;  and  in  nearly  all"  cases 
of  complete  fracture,  especially  in  such  as  are  at- 
tended with  depression,  the  internal  table  shows 
more  extensive  splintering  than  does  the  external. 
There  are   many  reasons  for  this.     The   internal 


II] 


FRACTDKES    OF    THE    SKULL 


25 


plate  is  not  only  thinner  than  the  external,  but  is 
so  much  more  brittle  as  to  receive  the  name  of  the 
"vitreous  table."  A  force  applied  to  the  external 
table  may  be  extremely  limited,  and  produce,  as  in 
a  sabre  cut,  but  a  limited  lesion.     As  the  force, 

C 


however,  travels  through  the  diploe  it  becomes 
broken  up,  and  reaches  the  inner  plate  as  a  much 
more  diffused  form  of  violence.  This  is  especially 
the  case  when  parts  of  the  outer  table  are  driven 
in.  Then,  again,  the  internal  plate  is  a  part  of  a 
smaller  curve  than  is  the  external  plate  ;  and, 
lastly,  Agnew  assigns  a  reason  for  the  greater  vul- 


C     3J 


Fig.  8. 

nerability  of  the  inner  plate  that  has  reference 
to  the  general  yielding  of  the  bone.  In  Fig.  7,  ab 
represents  a  section  of  a  part  of  the  vault  through 
both  tables,  and  c  D  and  E  f  two  vertical  and  paral- 
lel lines.  Now,  if  force  be  applied  to  the  vault  be- 
tween these  parallel  lines,  the  ends  of  the  arch, 


26  THE    HEAD    AND    NECK  [Chap. 

A  b,  will  tend  to  become  separated,  and  the  whole 
arch,  yielding,  will  tend  to  assume  the  curve  shown 
in  Fig.  8.  In  such  case,  the  lines  CD  and  ef  will 
converge  above  and  diverge  below  (Fig.  8),  so  that 
the  violence  would  tend  to  force  the  bone  particles 
together  at  the  outer  table  and  asunder  at  the 
inner  table. 

Fractures  of  the  vault  are  due  to  direct  vio- 
lence. The  construction  of  the  skull  is  such  that 
the  fracturing  force  is  resisted  in  many  ways. 
(1)  When  a  blow  is  received  on  the  vertex  in  the 
parietal  region,  the  force  tends  to  drive  the  upper 
borders  of  the  two  parietal  bones  inwards.  Such 
driving-in  of  these  borders  must  be  associated  with 
a  corresponding  outward  movement  of  the  inferior 
borders.  This  latter  movement  is  forcibly  resisted 
by  the  squamous  bone  and  the  great  wing  of  the 
sphenoid,  which  overlap  the  lower  edge  of  the 
parietal  bone.  Moreover,  the  force  transmitted  to 
the  squamous  bone  is  passed  on  to  the  zygomatic 
arch,  which  takes  its  support  from  the  superior 
maxillary  and  frontal  bones.  This  arch  then  acts  as 
a  second  resisting  buttress,  and  this  transmission 
of  force  from  the  vertex  to  the  facial  bones  is  said 
to  be  illustrated  by  the  pain  often  felt  in  the  face 
after  blows  upon  the  top  of  the  head.  (2)  If  the 
upper  part  of  the  frontal  bone  be  struck,  the  force 
is  at  once  transmitted  to  the  parietal  bones,  be- 
cause the  upper  part  of  the  frontal  bone  (owing  to 
the  manner  in  which  its  border  is  bevelled)  actu- 
ally rests  upon  the  two  parietal  bones ;  so  the  same 
resistance  is  again  called  into  action.  If  there  be  any 
tendency  for  the  inferior  parts  of  the  bone  to  move 
outwards,  as  would  certainly  be  the  case  while  the 
mid-frontal  suture  existed,  such  movement  would 
be  resisted  by  the  great  wings  of  the  sphenoid  and 
by  the  anterior  inferior  angles  of  the  parietal  bones 
which  embrace  or  overlap  these  parts  of  the 
frontal.  Thus  it  will  be  seen  that  much  depends 
upon  the  manner  in  which  the  corresponding  edges 
of  the  frontal  and  parietal  bones  are# bevelled.  (3) 
Blows  upon   the   occiput   are   less   distinctly  pro- 


IIJ  FRACTURES    OF    THE    SKULL  27 

vided  for,  and  it  must  be  owned  that  a  by  no 
means  heavy  fall  is  sufficient  to  break  this  bone. 
It  must  receive,  however,  much  protection  from 
its  connections  with  the  two  parietal  and  tem- 
poral bones,  and  from  its  articulation  with  the 
elastic  vertebral  column. 

Fractures  of  the  base  of  the  skull  may  be  due 
to  (1)  direct  or  (2)  indirect  violence,  or,  most 
commonly  of  all,  to  (3)  extension  of  a  fracture 
from  the  vault,  (l)  The  base  has  been  fractured 
by  direct  violence  due  to  foreign  bodies  thrust 
through  the  nasal  roof,  through  the  orbital  roof, 
and  through  the  base  as  it  presents  in  the  pharynx. 
The  posterior  fossa  can  also  be  fractured  by  vio- 
lence applied  to  the  nape  of  the  neck.  (2)  Of  frac- 
tures by  indirect  violence  the  following  examples 
may  be  given  :  Blows  applied  to  the  lower  part  of 
the  frontal  bone  have  been  associated  with  no 
lesion  other  than  a  fracture  of  the  cribriform 
plate  or  of  the  orbital  part  of  the  frontal, 
these  parts  being  much  disposed  to  fracture 
on  account  of  their  extreme  tenuity.  In  86 
cases  of  fracture  of  the  base  of  the  skull,  the 
orbital  roof  was  involved  in  79,  the  optic  foramina 
in  63,  and  the  cribriform  plates  in  nearly  all  (Raw- 
ling).  ^  In  falls  upon  the  chin,  the  condyle  of  the 
lower  jaw  has  been  so  violently  driven  against  the 
glenoid  cavity  as  to  fracture  the  middle  fossa  of 
the  skull.^  The  force  of  a  "  knock-out "  blow  applied 
to  the  point  of  the  chin  produces  concussion  of  the 
brain  without  fracture  of  the  skull.  When  the  body 
in  falling  has  alighted  upon  the  feet,  knees,  or  but- 
tocks, the  force  has  been  transmitted  along  the 
vertebral  column,  and  has  led  to  fracture  of  the 
base  in  the  occipital  region.  Such  accidents  are 
most  apt  to  occur  when  the  spine  is  kept  rigid  by 
muscular  action,  and  the  mechanism  involved  is 
precisely  similar  to  that  whereby  the  head  of  a 
broom  is  driven  more  firmly  on  to  the  broom-handle 
bv  striking  the  extreme  end  of  the  stick  ^  against 
the  ground.  The  theory  that  the  base  is  often 
broken  by  contre-coup  is  pretty  generally  abandoned, 


28  THE    HEAD    AND    NECK  [Chap. 

though  there  are  a  few  cases  that  appear  to  support 
the  suggestion.  Such  a  case  was  recorded  by  Sir 
J.  Hutchinson,  and  in  it  a  fracture  of  the  occipital 
bone  was  associated  with  a  like  lesion  in  the  cribri- 
form plate,  the  intervening  part  of  the  skull  being 
uninjured.  (3)  Fractures  of  the  vault,  and  especi- 
ally linear  fractures  due  to  such  diffused  violence 
as  obtains  in  a  fall  upon  the  head,  are  very  apt  to 
spread  to  the  base.  In  so  spreading  they  reach  the 
base  by  the  shortest  possible  route,  and  without 
any  regard  to  the  sutures  encountered  or  to  the 
density  of  the  bones  involved.  Thus,  fractures  of 
the  frontal  region  of  the  vault  spread  to  the  an- 
terior fossa  of  the  base,  those  of  the  parietal  region 
to  the  middle  fossa,  and  those  of  the  occipital 
region  to  the  posterior  fossa.  To  this  rule  there  are 
but  few  exceptions.  To  indicate  more  precisely 
the  exact  bones  involved  in  these  three  districts, 
P.  Hewett  has  divided  the  skull  into  three  zones. 
The  anterior  zone  includes  the  frontal,  the  upper 
part  of  the  ethmoid,  and  the  f ronto-sphenoid ;  the 
middle,  the  parietals,  the  squamous  and  anterior 
part  of  the  petrous  of  the  temporals,  and  the 
greater  part  of  the  basi-sphenoid ;  and  the  pos- 
terior, the  occipital,  the  mastoid,  the  posterior 
part  of  the  petrous  bone,  with  a  small  part  of 
the  body  of  the  sphenoid. 

In  all  fractures  of  the  base  there  is  usually  a 
discharge  of  blood  and  of  cerebro-spinal. fluid  ex- 
ternally. (1)  In  fractures  of  the  anterior  fossa  the 
blood  usually  escapes  from  the  nose,  and  is  derived 
from  the  meningeal  and  ethmoidal  vessels,  or  in 
greater  degree  probably  from  the  torn  mucous  lin- 
ing of  the  nasal  roof.  To  allow  of  the  escape  of 
cerebro-spinal  fluid  from  the  nose,  there  must  be, 
in  addition  to  the  fracture  in  the  nasal  roof,  a  lacer- 
ation of  the  mucous  membrane  below  that  fracture, 
and  of  the  sheaths  of  the  olfactory  nerves  which  are 
derived  from  the  dura  mater  and  arachnoid.  A 
profuse  discharge  of  cerebro-spinal  fluid  may  take 
place  through  the  nasal  mucous  membrane  inde- 
pendently of  inj  ury.    The  discharge  probably  occurs 


II j  FKACTUBES    OF    THE    SKULL  29 

along  the  sheaths  of  the  olfactory  nerves,  and 
is  caused  by  a  lessened  absorption  or  increased 
secretion  of  cerebro-spinal  fluid.  In  many  cases 
of  fracture  in  this  part  the  blood  finds  its  way  into 
the  orbit,  and  appears  beneath  the  conjunctiva. 
(2)  When  the  middle  fossa  is  involved,  the  blood 
escapes  from  the  external  auditory  meatus,  through 
a  rupture  in  the  tympanic  membrane,  and  is  de- 
rived from  the  vessels  of  the  tympanum  and  its 
membrane,  or  from  an  intracranial  extravasation, 
and  in  some  cases  from  a  rupture  of  the  cavernous 
or  petrosal  sinuses.  The  blood  may  follow  the 
Eustachian  tube,  and  may  escape  from  the  nose  or 
mouth,  or  be  swallowed  and  subsequently  vomited. 
To  allow  of  the  escape  of  cerebro-spinal  fluid  by  the 
ear  ("the  serous  discharge  "),  (a)  the  fracture  must 
have  passed  across  the  internal  auditory  meatus  ; 
(b)  the  tubular  prolongation  of  the  membranes  in 
that  meatus  must  have  been  torn ;  (c)  there  must 
be  a  communication  between  the  internal  ear  and 
the  tympanum  ;  and  (d)  the  membrana  tympani 
must  have  been  lacerated.  (3)  In  fractures  of  the 
posterior  fossa  an  extravasation  of  blood  may  ap- 
pear about  the  mastoid  process  or  at  the  nape  of 
the  neck,  or  may  even  extend  into  the  cervical  region. 

It  may  be  added  that  in  compound  fractures 
of  the  vault  associated  with  tearing  of  the  dura 
mater  and  arachnoid,  an  escape  of  cerebro-spinal 
fluid  has  in  a  few  rare  instances  been  noted.  After 
simple  fracture  of  the  vault  in  children  a  swelling 
may  form  at  the  injured  part  which  fluctuates,  be- 
comes tenser  when  the  patient  cries,  and  may  pos- 
sibly pulsate  synchronously  with  the  brain.  Such 
swellings  are  due  to  a  collection  of  cerebro-spinal 
fluid  beneath  the  scalp,  and  indicate  a  coincident 
rupture  of  the  brain  membranes. 

Separation  of  sutures. — This  condition,  as 
the  result  of  injury,  is  practically  restricted  to  the 
young  skull.  In  later  life,  force  applied  at  the  site 
of  an  obliterated  suture  may  cause  a  fracture, 
which  accurately  follows  the  old  suture  line.  Separ- 
ation of  the  sutures,  independent  of  fracture,  is 


30  THE    HEAD    AND    NECK  [Chap.  II 

very  rare  in  the  adult  skull.  In  the  few  instances 
of  such  a  condition  the  temporal  bone  has  usually 
been  the  one  displaced  and  the  separation  noted 
at  the  squamous  suture.  When  associated  with 
fracture,  the  coronal  and  sagittal  sutures  are  those 
most  frequently  separated,  and  the  next  in  fre- 
quency is  the'  lamb  do  id. 

The  thickness  of  the  skull  cap  varies 
greatly,  not  only  in  different  parts  of  the  same 
skull,  but  also  in  corresponding  parts  in  different 
individuals  t  The  average  thickness  is  J  of  an  inch. 
It  varies  with  age;  at  birth  the  parietal  is  less 
than  A  of  an  inch ;  at  three  years  diploe  appear, 
marking  off  the  inner  from  the  outer  table  of  the 
skull ;  in  old  people  the  parietal  bone  may  be  J  of 
an  inch  or  J  of  an  inch  in  thickness.  The  thickest 
parts  are  at  the  occipital  protuberance  (where 
the  section  may  measure  J  an  inch),  the  mastoid 
process,  and  the  lower  part  of  the  frontal  bone. 
The  bone  over  the  inferior  occipital  fossae  and  orbit 
is  very  thin,  while  it  is  thinnest  over  the  squamous 
bone.  Here  the  bone  may  be  no  thicker  in  parts 
than  a  visiting  card.  The  skull  is  also  thinned 
over  the  sinuses  and  grooves  for  the  meningeal 
vessels.  It  is  especially  thin  over  the  anterior  in- 
ferior angle  of  the  parietal  bone.  It  is  important 
to  remember  in  trephining  that  the  inner  table  is 
not  always  parallel  with  the  outer. 

Craniectomy.  —  This  operation  is  carried  out 
in  cases  of  microcephaly  in  infants  and  chil- 
dren. It  consists  in  the  removal  of  a  strip  of  bone 
from  the  vertex  of  the  skull  so  as  to  give  to  the 
brain,  as  an  American  author  expresses  it,  "  more 
elbow  room."  The  operation  presumes  that  the 
arrest  of  growth  in  the  brain  is  due  to  a  retarded 
growth  of  the  skull,  but  all  the  evidence  at  our  dis- 
posal points  to  the^  arrest  in  the  development  of 
the  brain  as  the  primary  lesion;  the  condition  of 
the  skull  being  a  consequence.  In  hydrocephalv 
the  skull  is  seen  to  respond  readily  to  the  quick 
expansion  of  the  brain  ;  if  the  growth  of  the  brain 
is  arrested,  the  skull  remains  small. 


CHAPTER  III 
THE   CRANIAL    CONTENTS 

Membranes    of    the    brain.— The  dura  mater, 

from  its  toughness,  forms  an  excellent  protec- 
tion to  the  brain.  It  is  very  intimately  adherent 
to  the  bone  over  the  whole  of  the  base  of  the 
skull,  and  consequently  in  this  situation  extrava- 
sations between  the  membrane  and  the  bone  are 
scarcely  possible.  Over  the  vault  its  attachments 
are  comparatively  loose,  although  it  is  more  closely 
adherent  along  the  lines  of  the  sutures.  This  lax 
attachment  allows  large  hemorrhagic  and  puru- 
lent extravasations  to  collect  between  the  dura 
mater  and  the  bone.  Such  extravasations  usually 
lead  to  compression  of  the  brain,  and  it  may  be 
noted  that  in  the  great  majority  of  all  cases  of 
compression  the  compressing  force  is  outside  the 
dura  mater.  Thus,  in  uncomplicated  cases  when 
symptoms  of  compression  come  on  at  the  time  of 
an  accident,  the  cause  is  probably  depressed  bone ; 
when  they  appear  after  a  short  interval,  the  cause 
is  probably  extravasated  blood  between  the  mem- 
brane and  the  bone;  and  when  a  long  interval 
(days  or  weeks)  has  elapsed  after  the  accident,  the 
cause  is  probably  a  collection  of  pus  in  the  same 
situation. 

Sir  C.  Bell  pointed  out  that  the  dura  mater  of 
the  vault  may  be  separated  from  the  bone  by  the 
vibration  produced  by  a  blow.  "Strike  the  skull 
of  a  subject  with  a  heavy  mallet ;  on  dissecting  you 
find  the  dura  mater  to  be  shaken  from  the  skull  at 
31 


32  THE    HEAD    AND    NECK  [Chap. 

the  point  struck.  Repeat  the  experiment  on  an- 
other subject,  and  inject  the  head  minutely  with 
size  injection,  and  you  Trill  find  a  clot  of  injection 
lying  betwixt  the  skull  and  dura  mater  at  the  part 
struck,  and  having  an  exact  resemblance  to  the 
coagulum  found  after  violent  blows  on  the  head." 
Tillaux  has  demonstrated  that  the  adhesions  be- 
tween the  dura  mater  and  the  bone  are  particularly 
weak  in  the  temporal  fossae,  the  most  usual  site  of 
meningeal  haemorrhage. 

When  blood  is  poured  out  between  the  dura 
mater  and  the  bone  in  cases  of  fracture,  the 
vessel  that  as  a  rule  gives  way  is  the  middle 
meningeal  artery*  In  thirty-one  cases  of  such 
haemorrhage,  this  vessel  was  the  source  of  the 
bleeding  in  twenty-seven  instances  (P.  Hewett). 
The  vessel,  having  passed  through  the  foramen 
spinosum,  divides  into  two  branches  ;  the  anterior, 
the  larger,  runs  upwards  across  the  anterior  in- 
ferior angle  of  the  parietal  bone  and  ascends  the 
vault  some  distance  behind  the  coronal  suture  ; 
the  posterior  runs  backwards,  with  a  horizontal 
sweep  across  the  squamous  bone,  and  takes  the 
course  of  the  second  temporal  convolution.  (See 
Figs.  2,  3.) 

Mr.  Jacobson  has  shown  that  the  branches  of 
the  artery  are  more  frequently  ruptured  than  the 
trunk.  The  vessel  is  very  frequently  torn  as  it 
crosses  the  anterior  angle  of  the  parietal  bone. 
There  are  many  reasons  for  this  :  the  bone  where 
grooved  by  the  artery  is  very  thin  ;  the  artery  is 
often  so  embedded  in  the  bone  that  fracture  with- 
out laceration  of  the  vessel  would  hardly  be  pos- 
sible ;  and  lastly,  the  particular  region  of  the 
artery  is  a  part  of  the  skull  peculiarly  liable  to  be 
fractured.  Mr.  Jacobson  shows  that  the  artery  may 
be  ruptured  by  a  force  that  does  not  fracture  the 
skull,  but  merely  leads  to  detachment  of  the  dura 
mater.  Failing  this  vessel,  the  most  frequent 
source  of  extrameningeal  haemorrhage  is  the 
lateral  sinus,  for  reasons  that  will  be  obvious. 

Venous  sinuses. — The  flaccid-walled  cerebral 


Ill]  VENOUS    SINUSES  33 

veins,    which    are    compressed    with    each    pulsa- 
tion of  the  brain,  empty  into  the  venous  sinuses, 
rigid-walled  cavities  formed  between  the  outer  or 
periosteal  and  inner  or  supporting  layers  of  the 
dura  mater.     At  the   points  where  the   superior 
cerebral    veins    enter    the    superior    longitudinal 
sinus,    and    where    the    temporo-sphenoidal    and 
occipital  veins  join  the  lateral  sinus,  the  arach- 
noid,  elsewhere  free  from  dura  mater,   is  firmly 
adherent  to   it.     From  a  surgical  point  of  view 
the   lateral   is  the  more  important  sinus ;  and  as 
it  turns  downwards  beneath  the  mastoid  process 
it  comes  into  close  relationship  with  the  antrum 
and  cells  of  the  mastoid,  from  which  a  septic  con- 
dition may  spread  to  the  sinus,  setting  up  throm- 
bosis  (see  Fig.    22,    p.    90).      The  lateral   sinus   is 
marked  out  by  taking  the  following  three  points 
(see   Fig.    2,    p.    9,    and   Fig.    3,    p.    12)  :    (1)    The 
inion,  (2)  the  asterion,  (3)  a  point  i  an  inch  behind 
the  lower  border  of  the  meatus.    When  these  three 
points  are  joined,  the  lateral  sinus  is  seen  to  be 
made  up  of  two  parts — a  horizontal,  which  gradu- 
ally  ascends   as   it  passes   from  the   inion  to  the 
asterion;  and  a  vertical,  which  rapidly  descends 
from  the   asterion  to  the  postmeatal  point.     The 
sinus  is  10  mm.  wide.   The  lateral  sinus  escapes  from 
the  skull  to  form  the  internal  jugular  vein  in  line 
with  the  anterior  border  of  the  mastoid  process, 
but    situated   deeply   beneath   the   parotid   gland 
(Fig:.  2,  p.  9).    A  line  drawn  over  the  vault  of  the 
skull  from  nasion  to  inion  marks  the  line  of  the 
superior  longitudinal  sinus  ;   beneath  the  posterior 
third  of  the  sagittal  suture  it  may  not  keep  exactly 
to  the  middle  line,  and  in  this  part  of  its  course 
it  frequently  shows  lateral  extensions  or  diverti- 
cula known   as   parasinoids.     In  the  majority  of 
cases  the  superior  longitudinal  ends  in  the  right 
lateral    sinus,    which    is   hence    commonly    larger 
than  the  left.     The  cavernous  sinus,  enclosing  the 
internal   carotid   artery   and    sixth   cranial   nerve, 
with  the  third,    fourth,   and  greater   part  of  the 
fifth   embedded   in   its  wall,    is   situated  over  the 
c 


34  THE    HEAD    AND    NECK  [Chap. 

sphenoidal  air  sinus,  from  which  septic  conditions 
may  extend  to  it,  giving  rise  to  thrombosis.  In 
such  cases  the  eyes  become  prominent  owing  to  the 
distension  of  the  ophthalmic  veins,  for  the  venous 
stream  from  the  orbit  flows  through  the  cavernous 
sinus  to  reach  the  lateral  sinus  and  jugular  vein  by 
means  of  the  superior  and  inferior  petrosal  sinuses. 
Tumours  of  the  pituitary  necessarily  compress  the 
cavernous  sinus.  The  relations  between  the  in- 
ternal carotid  artery  and  cavernous  sinus  are  so 
intimate  that  an  arterio-venous  aneurysm  has 
followed  injury  involving  these# parts.  It  will  be 
seen  also  with  what  ease  this  sinus  could  become 
thrombosed  in  cases  of  inflammation  within  the 
orbit  by^  the  extension  of  the  mischief  along  its 
great  tributaries,  the  two  ophthalmic  veins. 

Between  the  dura  mater  and  the  arachnoid  is 
the^  subdural  space,  which,  like  the  pleural 
cavity,  is  merely  a  potential  space,  for  in  health 
the  arachnoid  is  closely  applied  to  the  smooth 
inner  surface  of  the  dura  mater.  A  space  is  formed 
only  when  fluid,  blood,  or  pus  is  collected  between 
the  two  membranes  (Fig.  1,  p.  2).  The  subdural 
space  contains  a  small  amount  of  fluid,  and  acts, 
like  the  pleural  and  peritoneal  sacs,  in  prevent- 
ing the  effects  of  friction  during  the  pulsatory 
movements  of  the  brain. 

A  knowledge  of  the  subarachnoid  space  is 
steadily  becoming  of  greater  surgical  importance. 
The  space  which  surrounds  the  spinal  cord  is  in 
direct  continuity  with  the  subarachnoid  spaces  of 
the  brain,  and  hence,  when  this  space  is  tapped 
in  the  lumbar  part  of  the  spinal  canal  (Fig.  135, 
p.  641),  the  fluid  situated  in  the  subarachnoid 
spaces  of  the  brain  is  also  drained  off  (Fig.  9).  In 
meningitis  the  cerebro-spinal  fluid  becomes  turgid; 
the  subarachnoid  space,  or  parts  of  it,  may  contain 
pus.  In  the  spinal  column  the  arachnoid  is  widely 
separated  from  the  nia  mater,  hence  the  subarach- 
noid space  is  extensive.  As  the  space  passes  into 
the  skull  it  forms  an  expansion  between  the  cere- 
bellum and  roof  of  the  fourth  ventricle  named  the 


Ill] 


SUBARACHNOID    SPACE 


35 


cisterna  magna  (Fig.  9);  an  opening  in  the  roof 
of  the  fourth  ventricle  (the  foramen  of  Magendie) 
allows  the  cerebro-spinal  fluid  in  the  ventricles  of 
the  brain  to  join  that  in  the  cisterna  magna  (Fig. 
9).  On  the  base  of  the  skull,  in  front  of  the  medulla 
and  pons,  the  spinal  subarachnoid  space  expands 
into  the  cisterna  pontis,  which  in  turn  becomes 
continuous  with  a  large  space  situated  on  the  base 
of  the  brain  between  the  temporal  lobes  and  under 


eoce  of  arachnoid 

Supra-Callosal  Space 

ERAlVENTRICIE- 
CE/1U 


CALL050  ttARClNAL  SPACE 

Supra  Callosai  Space 

splenium 
Velum  InterpositunI 

Pt/IEAL  CLA»D 


Tentorium  Cerebeui 
Aqueduct  op  Sylviu: 
Fourth  Ventricle 
Foramen  ©p/^acendie. 
Cisterna  macna 


Foramen  op 

MONRO 

Third 
"entricle 

ub  Callosu 
Space 
Cisterna 

BA5ALI5 

Optic 

/terve 
Pituitary 

Body 
^Internal 
;arotio  art- 


Fig.  9. — Diagram  of  the  cranial  spaces  containing 
cerebro-spinal  fluid. 


the  interpeduncular  space — the  cisterna  basalis 
(Fig.#  9).  In  this  cistern  are  situated  the  circle  of 
Willis,  the  third,  fourth,  and  root  of  the  fifth 
nerves,  the  optic  chiasma  and  tracts  and  infundi- 
bulum  of  the  pituitary  body.  In  basal  meningitis 
it  may  become  distended  with  pus.  The  inflam- 
matory adhesions  which  occur  in  the  inferior 
medullary  velum  may  lead  to  a  condition  of 
hydrocephaly  by  closing  up  the  openings  in  that 
membrane.  Over  the  convolutions  of  the  brain 
the  arachnoid  is  bound  by  the  pia  mater,  which 


36  THE    HEAD    AND    NECK  [Chap. 

here  serves  as  a  loose  subarachnoid  tissue.  Every- 
where extensions  of  the  basilar  cistern  pass  out 
with  the  arteries  derived  from  the  circle  of  Willis 
into  the  pia  mater  in  the  sulci  of  the  brain.  While 
the  interpeduncular  part  of  the  base  of  the  brain, 
pons  and  medulla  rest  on  these  basal  cisterns,  the 
temporal  and  frontal  lobes  lie  directly  on  the  base 
of  the  skull ;  the  occipital  lobe  rests  on  the  ten- 
torium cerebelli.  The  three  poles  of  the  brain — 
the  frontal,  occipital,  and  temporal — are  in  direct 
contact  with  the  meninges  and  skull,  and  are 
therefore  the  parts#  of  the  brain  that  are  most 
liable  to  laceration  in  cases  of  injury  to  the  head. 

The  cerebro-spinal  fluid  prevents  the  ill  effects 
that  irregularities  in  the  blood  circulation  might 
have  upon  the  brain,  situate  as  it  is  within  an  un- 
yielding cavity.  If  the  great  nerve  centres  near  the 
lateral  ventricles  are  swollen  by  congestion,  they 
are  not  met  by  an  unyielding  wall,  but  merely  dis- 
place some  of  the  cerebro-spinal  fluid  through  the 
foramen  of  Magendie,  until  such  time  as  their 
circulation  is  normal  again.  When  the  healthy 
brain  is  exposed  by  a  trephine  opening  it  is  seen 
to  pulsate  with  each  beat  of  the  heart;  if  it  does 
not  pulsate,  this  shows  that  the  pressure  within 
the  skull  is  higher  than  the  arterial  pressure 
(100-130  mm.  Hg) ;  normally,  as  Hill  has  shown, 
the  intracranial  pressure  is  that  of  the  blood- 
pressure  in  the  veins  (10-15  mm.  Hg).  With  each 
pulsation  of  the  heart  about  5  c.c.  of  arterial  blood 
is  thrown  into  the  skull,  causing  the  ejection  of  a 
similar  amount  of  venous  blood  by  the  jugular 
vein. 

Fluid  may  pass  from  the  lateral  to  the  third 
ventricle  by  the  foramen  of  Monro  :  from  the  third 
to  the  fourth  ventricle  by  the  aqueduct  of  Sylvius ; 
and  from  the  fourth  ventricle  >  to  the  cisterna 
magna  by  the  foramen  of  Magendie  (Fig.  9).  Many 
still  share  the  opinion  of  Hilton  that  blockage 
of  the  aqueduct,  or  closure  of  the  foramen  of 
Magendie,  or  of  the  other  two  openings  at  the 
lateral  angles  of  the  fourth  ventricle   (the  fora- 


Ill]  CEREBKO-SPINAL    FLUID  37 

mina  of  Key  and  Retzius)  may  prevent  the  exit  of 
cerebro-spinal  fluid  from  the  ventricles  and  thus 
produce  the  condition  of  hydrocephaly.  The  fluid 
also  drains  into  the  veins  of  Galen,  hence  pressure 
on  these  may  bring  about  a  like  result.  It  has  been 
proposed  to  relieve  the  pressure  within  the  lateral 
ventricles  in  cases  of  hydrocephaly  by  draining  the 
cerebro-spinal  fluid  into  the  subdural  space  by 
means  of  a  seton.  It  is  absorbed  under  any  pressure 
above  that  within  the  cerebral  veins  (Hill).  If  the 
brain,  too,  becomes  enlarged  by  congestion,  it  is 
not  met  by  unyielding  bone,  but  rather  by  an  ad- 
justable water-bed,  and  during  its  period  of  en- 
largement it  merely  displaces  into  the  spinal  part 
of  the  subarachnoid  space  some  of  the  fluid  that 
surrounds  it.  This  mutual  effect  is  well  illustrated 
in  a  case  reported  by  Hilton  of  a  man  with  a  frac- 
ture of  the  base,  from  whose  ear  cerebro-spinal 
fluid  was  escaping.  The  discharge  of  this  fluid 
was  at  once  greatly  increased  by  expiratory  efforts 
when  the  nose  and  mouth  were  held  closed  and  the 
veins  compressed  in  the  neck. 

» Cerebro-spinal  fluid. — The  total  amount  of 
fluid  in  the  cerebro-spinal  system  of  an  adult  is 
estimated  at  100-130  c.c.  (about  4  oz.).  It  is 
secreted  by  the  choroid  plexuses  (1)  in  the  lateral 
ventricles,  (2)  in  the  roof  of  the  third  ventricle, 
and  (3)  in  the  roof  of  the  fourth  ventricle,  the 
ependymal  epithelium  covering  these  plexuses 
being  regarded  as  the  actual  structure  carrying 
out  the  secretion.  The  fluid  is  absorbed  by  (1) 
the  lymphatic  spaces  surrounding  the  nerve  roots, 

(2)  by  passage  into  veins  and  venous  spaces,  and 

(3)  the  Pacchionian  bodies  may  also  serve  as  a 
means  whereby  it  enters  the  venous  system. 
Methylene  blue,  when  injected  into  the  spinal 
subarachnoid  space,  quickly  appears  in  the  ven- 
tricles of  the  brain,  from  which  we  see  that 
diffusion  takes  place  rapidly. 

Pituitary  body,_In  recent  years  the  pitui- 
tary body,  enclosed  within  a  special  compartment 
of    the    dura    mater,    and    placed    on    the    upper 


38 


THE    HEAD    AND    NECK 


LChap. 


surface  of  the  basi-sphenoid,  has  assumed  an 
increased  surgical  importance.  In  Fig.  10  its 
form  and  relationships  are  shown  as  seen  in  a 
young  child.  Its  stalk  descends  from  the  floor 
of  the  third  ventricle,  and  ends  in  the  posterior 
or  neural  lobe.  The  anterior  or  glandular  lobe 
is  applied  to  the  neural  lobe  and  embraces  it  on 
each   side.     The  glandular   lobe,    which  arises  as 


3rd  Ventricle 

Optic  Chiasma 

Arach. 
Dura  Mater 
Infundibulum 
Presphen. 
Perineural  Lobe 
Preneural  Lobe 


Dorsum  Sell-« 
Basilar  Art. 


Track  of  Development 


Septum  Nasi 
fharyng.  Pituitary 


Fig.  10. — Section  of  the  pituitary  body,  third  ventricle, 
basi-sphenoid,  and  naso-pharynx  of  a  child  aged  15 
months.  The  remnant  of  the  stalk  of  the  pituitary  out- 
growth is  represented  in  the  roof  of  the  naso-pharynx. 

an  outgrowth  from  the  stomodseum  or  mouth- 
depression  of  the  embryo,  is  divided  into  two 
parts — a  perineural,  which  is  closely  applied  to 
the  neural  lobe,  and  an  anterior  or  preneural 
part.  The  perineural  and  preneural  parts  are 
separated  by  a  central  cavity,  which  is  obliterated 
as  adult  life  is  reached  (Fig  10).  The  preneural 
glandular  part  may  become  hypertrophied  and 
form  a  glandular  tumour,   and  in  many  of  these 


Ill]  PITUITARY    BODY  39 

cases  various  parts  of  the  body — especially  the 
face,  hands  and  feet^begin  to  grow,  and  attain 
a  large  size,  giving  rise  to  the  condition  known 
as  acromegaly.  If  the  hypertrophy  occurs  in 
youth,  then  all  the  bones  of  the  skeleton  grow 
rapidly,  and  the  condition  of  giantism  is^  pro- 
duced. The  preneural  glandular  part  of  the 
pituitary — evidently  by  means  of  an  internal  se- 
cretion— regulates  the  growth  of  the  various  parts 
of  the  body,  and,  if  secretion  is  in  excess,  leads 
to  overgrowth.  Numerous  cases  have  been  relieved 
by  operation,  part  of  the  glandular  lobe  being 
scraped  away.  In  the  adult,  access  to  the  pituitary 
is  obtained  through  the  sphenoidal  sinus,  on  the 
roof  of  which  this  body  is  situated.  The  sinus 
is  reached  by  reflecting  the  cartilaginous  part  of 
the  nose  and  following  the  septum  nasi  backwards 
until  the  sphenoidal  sinus  is  reached.  Pituitary 
tumours,  as  they  expand,  compress  the  cavernous 
sinuses,  and,  from  their  close  relationship  to  the 
optic  nerves,  lead  usually  to  a  partial  optic 
atrophy  and  blindness.  ^  The  tumour  may  depress 
the  roof  of  the  sphenoidal  sinus.  In  Fig.  10  a 
remnant  of  the  stalk  of  the  developing  pituitary  is 
shown  in  the  roof  of  the  naso-pharynx.  Erdlieim 
found  that  this  remnant  of  the  foetal  pituitary 
(the  naso-pharyngeal  pituitary)  occurred  in  every 
one  of  the  bodies  that  he  examined — over  fifty 
in  number.  The  blood  supply  of  the  pituitary  is 
from  numerous  vessels  which  arise  from  the  circle 
of  Willis  and  descend  in  the  stalk  of  the  pituitary. 
The  pituitary  is  contained  within  a  compartment 
of  the  dura  mater,  the  roof  of  which  is  perforated 
by  the  stalk  of  the  body. 

Surface  relationships  of  the  brain  (see 
Figs.  11  and  12). — The  longitudinal  fissure  of  the 
brain  is  indicated  by  a  line  drawn  along  the  vertex 
from  the  glabella  to  the  external  occipital  protu- 
berance. It  is  narrow  in  front,  but  as  it  contains 
the  longitudinal  sinus,  which  rapidly  enlarges  as 
it  passes  backwards,  it  becomes  of  considerable 
breadth    behind,    and    as    a    rule    lies    somewhat 


40 


THE    HEAD    AND    NECK 


[Chap 


towards  the  right  of  the  median  line,  owing  to  the 
predominance  of    the    left    cerebral    hemisphere. 


FISSUREof  ROLANDO. 


PARIETAL 
EMINEI 


BREGMA 


Fig.  11. — Showing  the  relation  of  the  brain  and  sensori- 
motor areas  of  the  cortex  to  the  skull-  (Modified  from 
Quain. ) 

The  sensori-motor  areas  are  shaded— the  leg  and  trunk  areas  with 
vertical  lines  ;  the  arm  and  hand  areas  with  lines  slanting  for- 
wards ;  the  face  and  mouth  areas  with  lines  slanting  back- 
wards ;  the  tongue,  pharynx,  and  larynx  areas  are  stippled.  The 
ascending  frontal  convolution,  containing  the  areas  which  are 
strictly  motor  in  function,  is  indicated  by  red  lines.  The  motor 
centre  for  speech  on  Broca's  convolution  is  shaded  with  horizontal 
lines.  The  "  word-hearing  "  centre  is  indicated  on  the  superior 
temporal  convolution,  and  the  "  word-seeing "  centre  on  the 
angular  convolution.  The  area  shaded  with  horizontal  lines  on 
the  posterior  parts  of  the  middle  and  inferior  frontal  convolutions 
is  the  centre  for  combined  movements  of  the  head  and  eyes. 


Between  the  external  occipital  protuberance  and 
the  ear,  the  lateral  sinus  bounds  the  lower  level  of 


Ill]  FISSURE    OF    ROLANDO  41 

the  cerebrum  and  the  upper  of  the  cerebellum 
(Figs.  3  and  11).  In  front  of  the  ear  the  upper 
border  of  the  zygoma  in  its  posterior  three-fourths 
marks  the  lower  border  of  the  temporal  lobe.  The 
pole  of  the  temporal  lobe  is  }  of  an  inch  behind  the 
outer  margin  of  the  orbit  (see  Fig.  3).  The  lower 
limit  of  the  brain  on  the  forehead  may  be  indicated 
approximately  by  drawing  a  line  from  the  glabella 
to  the  Sylvian  point,  \  an  inch  above  the  upper 
margin  of  the  orbit.  The  olfactory  bulbs  he  at 
the  level  of  the  nasion  (Fig.  3). 

The  cerebellum  is  best  explored  at  a  point  lj 
inches  behind  and  |  an  inch  below  the  level  of  the 
external  auditory  meatus  (see  Fig.  3,  p.  12).  ^  It 
is  deeply  placed,  being  covered  by  the  insertions 
of  the  occipital  muscles. 

Of  the  many  methods  which  have  been  sug- 
gested for  marking  out  the  fissure  of  Rolando, 
the  most  simple  and  accurate  is  the  following  :  A 
point  over  the  sagittal  suture  is  taken  ^  midway 
between  the  glabella  and  external  occipital  pro- 
tuberance. Half  an  inch  behind  this  mid-point 
the  upper  end  of  the  fissure  terminates  (Fig. 
12).  A  line  3i  inches  long  drawn  downwards  and 
forwards  from  this  point,  at  an  angle  of  67°  to 
the  .line  of  the  sagittal  suture,  will  indicate  the 
position  of  the  fissure  of^  Rolando  in  the  adult. 
In  the  child  the  fissure  is  shorter  and  the  con- 
tained angle  is  5°  smaller.  The  angle  is  easily 
obtained  by  folding  twice  the  corner  of  a  square 
piece  of  paper  and  removing  a  fourth  of  the 
right  angle.  This  line  may  not  lie  exactly  over 
the  fissure,  for  it  varies  somewhat  in  position 
according  to  the  shape  of  head.  The  sensori- 
motor areas  of  the  brain  are  mostly  represented 
in  the  ascending  frontal  and  parietal  convolu- 
tions which  bound  the  fissure  of  Rolando.  The 
average  .  width  of  each  of  these  convolutions  is 
f  of  an  inch.  The  coronal  suture  is  about  2  inches 
in  front  of  the  fissure  of  Rolando  at  its  upper 
part   and  \\  inches  at  its  lower. 

The    fissure    of  Sylvius    is    indicated    thus 


42 


THE    HEAD    AND    NECK 


[Chap. 


(Fig.  12)  :  A  point  is  taken  lj  inches  behind 
and  |  an  inch  above  the  fronto-malar  junction, 
which  is  indicated  by  a  distinct  notch.     This  point 


UPPER 
R0LA/1DIC  POINT 


Fig.   12. — Showing  the  lines  which  indicate  the  position  of 
the  principal  fissures  of  the  brain. 

Reid's  base  line  is  drawn  from  the  lower  margin  of  the  orbit  back- 
wards through  the  meatal  point. 


on  the  temple  overlies  the  anterior  inferior  angle 
of  the  parietal  bone — the  pterion.  The  pterion 
marks  the  j  unction  of  the  three  limbs  of  the 
fissure  of   Sylvius  with  its  stem.     A  line   drawn 


1I1J  FISSURE    OF    SYLVIUS  43 

backwards   and   upwards   from  the   pterion   to   a 
point  |  of  an  inch  below  the  parietal  eminence 
indicates  the  situation  of  the  posterior  horizontal 
limb  or  ramus  (Fig.  12).     If  the  parietal  eminence 
be  not  well  marked,  then  the  fissure  may  be  in- 
dicated by  joining  the   fronto-malar   notch  with 
the  pterion  and  prolonging  the  line  thus  formed 
straight  backwards  to  the  region  of  the  parietal 
eminence,  as  shown  in  Fig.  3  (R.  J.  Berry).     This 
ramus  is  bounded  below  by  the  superior  temporal 
convolution,   which  contains  in   its  middle  third 
the  "  word-hearing "   centre  (Fig.    11).     Above,   it 
is  bounded  from  before  backwards  by  the  basilar 
part  of  the  inferior  frontal  convolution,  the  lower 
ends  of  the  ascending  frontal  and  parietal  con- 
volutions, and  the  supramarginal  gyrus.     In  the 
three  parts  first  named  are  situated  centres  for 
movements  of  the  tongue,   larynx,   pharynx  and 
mouth.     A  penny  piece  placed  directly  behind  the 
termination   of  the    Sylvian   line   will   cover   the 
angular  convolution  in  which  the  "word-seeing  V 
centre  is  placed  (Fig.  11).     The  parietal  eminence 
covers  the  supramarginal  convolution.   The  ascend- 
ing  limb   of  the   fissure   of   Sylvius   is   indicated 
by  a  line  j  of  an  inch  long  drawn  upwards  and 
slightly  forwards  from  the  pterion,  while  the  short 
anterior  horizontal  limb   is   indicated  by   a   line 
\  an   inch  long   drawn   forwards  from  the  same 
point.     Between  the  ascending  and  anterior  limbs 
is  situated  the  pars  triangularis  of  the  inferior 
frontal    convolution    in    which    the    centre    for 
"  motor  speech  ,;   is  placed.     Broca  regarded  the 
left     inferior     frontal  >  convolution     (frequently 
called  Broca's  convolution)  as  specially  connected 
with  speech,  but  recently  Pierre  Marie  has  pub- 
lished accounts  of  a  number  of  cases  of  disease  of 
this   part   in   which   speech   was   unaffected.     The 
stem  of  the  Sylvian  fissure  is  \  an  inch  long  and 
runs   downwards   and   forwards   under   the  great 
wing   of  the   sphenoid    (Fig.    11).      The   temporal 
pole  lies  below  it. 

The    four    angles    of    the    parietal    bone    have 


44  THE    HEAD    AND    NECK  [('hap. 

important  relationships  to  the  brain.  The  anterior 
inferior  angle  covers  the  posterior  part  of  the  in- 
ferior frontal  convolution  and  the  anterior  hori- 
zontal and  ascending  limbs  of  the  fissure  of  Syl- 
vius. The  anterior  branch  of  the  middle  meningeal 
artery  ascends  beneath  it.  The  anterior  superior 
angle  at  the  bregma  covers  the  terminal  part  of 
the  superior  frontal  convolution  and  the  centre 
for  movements  of  the  hip.  The  posterior  superior 
angle  at  the  lambda  lies  over  the  upper  part 
of  the  occipital  lobe  and  \  an  inch  behind  the 
parieto-occipital  fissure.  The  posterior  inferior 
angle  covers  the  convexity  of  the  lateral  sinus  and 
marks  the  lower  limit  of  the  cerebrum.  In  its 
anterior  half  the  posterior  limb  of  the  Sylvian 
fissure  lies  beneath  the  squamous  suture,  but  be- 
hind it  passes  entirely  beneath  the  parietal  bone. 
It  will  be  thus  seen  that  the  parietal  bone  covers 
the  whole  of  the  parietal  lobe,  the  posterior  parts 
of  the  frontal  and  temporo-sphenoidal  lobes,  and 
the  upper  margin  of  the  occipital. 

The  inferior  temporal  convolution  passes 
backwards  above  the  upper  border  of  the  zygoma 
and  external  auditory  meatus  and  rests  on  the 
thin  roof  of  the  tympanum.  Hence  it  is  the  most 
common  site  of  abscess  which  may  follow  middle- 
ear  disease.     (Fig.  11.) 

The  basal  ganglia  of  the  brain — the  corpus 
striatum  and  optic  thalamus — are  capped  on  their 
outer  aspect^  by  the  island  of  Reil.  The  island 
lies  buried  in  the  anterior  three-fourths  of .  the 
fissure  of  Sylvius,  and  hence  the  surface  markings 
for  the  fissure  may  be  also  used  for  the  island 
and  the  basal  ganglia  ^  (see  Fig.  3,^  p.  12).  A 
half-circle,  with  a  radius  of  ^  an  inch,  drawn 
in  front  of  the  pterion,  will  indicate  the  anterior 
limit  of  the  basal  ganglia,  while  their  posterior 
limit  lies  some  distance  in  front  of  the  point  at 
which  the  lateral  ventricles  may  be  tapped  (see 
Fig.  3,  p.  12).  That  point  is  found  thus  :  a 
line  5  cm.  (2  inches)  in  length  is  drawn  verti- 
cally upwards  from  the  external  auditory  meatus ; 


Ill]  SENSORI-MOTOR    AREAS  45 

the  point  for  tapping  the  lateral  ventricle  lies 
2  cm.  (J  of  an  inch)  behind  the  upper  end  of 
this  line;  a  trocar  thrust  in  there  enters  the 
lateral  ventricle  at  the  junction  of  the  body  with 
the  descending  and  posterior  horns.     (Jenkins.) 

Sensori-motor  areas  of  the  brain. — A 
knowledge  of  the  position  of  these  areas  is  most 
important  in  enabling  certain  brain  lesions  to  be 
localized  and  in  guiding  the  surgeon  in  operations 
upon  the  cerebral  cortex. 

Formerly  these  areas  were  believed  to  be  situ- 
ated in  the  ascending  frontal  (precentral)  and  also 
ascending  parietal  (postcentral)  convolution,  but 
by  stimulating  more  accurately  the  cortex  of  these 
convolutions  in  anthropoid  apes,  Sherrington  and 
Griinbaum  found  that  motor  reactions  were 
elicited  only  from  the  ascending  frontal.  The 
arrangement  of  the  motor  areas  is  shown  in  Fig. 
13  :  in  the  upper  third  of  the  ascending  frontal, 
passing  also  some  distance  on  to  the  mesial  aspect 
of  the  brain,  the  movements  of  the  lower  extremity 
and  trunk  are  represented;  in  the  middle  third, 
those  of  the  arm;  while  in  the  lower  third,  those 
of  the  face,  mouth,  and  larynx.  Behind  the  fis- 
sure of  Rolando,  in  the  ascending  parietal  con- 
volution, are  situated  sensory  areas  corresponding 
to  the  motor  areas  in  the  ascending  frontal  con- 
volution. A  tumour  pressing  on  the  surface  of 
the  brain  first  excites  the  cortex  to  action;  hence 
one  situated  over  a  motor  area  excites  the  move* 
ments  represented  in  that  area,  or  one  over  a  sen- 
sory area  excites  the  sensations  represented  there. 
Stimulation  of  the  cortex  is  soon  followed  by  its 
destruction  and  loss  of  function;  hence  loss  of 
movement  or  loss  of  sensation  replaces  the  pre- 
liminary excitement.  The  symptoms  produced  by 
intracranial  growths  are  apt  not  to  be  definitely 
localized,  because  even  a  small  tumour  may  pro- 
duce widely  distributed  compression  effects  when 
it  is  situated  within  the  rigid  walls  of  the  skull. 
Conjugate  movements  of  the  eyes  are  represented 
in   the  cortex  at  the   posterior   end  of  the  mid- 


46 


THE    HEAD    AND    NECK 


[Chap. 


frontal  convolution  (Fig.  13).  There  are  also 
several  primary  sensory  areas  of  cortex — areas 
connected  with  sight,  hearing,  and  smell — which 
may  be  affected  by  intracranial  lesions,  and  give 
signs  which  assist  the  surgeon  to  localize  the  seat 
of  disease.  The  visual  cortex  is  situated  near  the 
calcarine  fissure  and  round  the  occipital  pole; 
the  "word-seeing"  centre  occupies  the  angular 
gyrus  (Fig.  11)  ;  the  auditory  cortex  lies  in  a  deep 


Fig.  13. — Showing  the  localization  of  motor  areas  in  the 
precentral  or  ascending  frontal  convolution,  and  the  sensory 
areas  in  the  postcentral  or  ascending  parietal  convolution. 

or  buried  part  of  the  superior  temporal  convolu- 
tion, while  the  "  word-hearing  "  centre  is  ascribed 
to  the  middle  third  of  this  convolution.  The  ol- 
factory cortex  is  placed  in  the  uncus,  which  is 
situated  to  the  inner  side  of  the  temporal  lobe. 
Tumours  in  the  neighbourhood  of  the  uncus, 
besides  producing  disturbance  of  the  olfactory 
sensations,  frequently  give  rise  to  "dreamy 
states." 


Ill]  THE   BEAIN  47 

Of  the  brain  generally  little  has  to  be  said. 

In  a  surgical  sense,  it  presents  itself  simply  as  a 
large  mass  of  soft  tissue  that  may  be  damaged  by 
shaking,  as  gelatin  may  be  when  shaken  in  a  case. 
As  it  is  of  very  yielding  structure,  and  does  not 
entirely  fill  the  cranial  cavity,  it  may,*  as  it  were, 
be  thrown  about  with  the  skull,  and  be  damaged 
by  collision  with  its  walls.  <  In  contusion  or  bruis- 
ing of  the  brain  it  is  noticed  that  the  lesion  is 
very  much  more  frequently  situate  on  the  under 
surface,  both  as  regards  the  cerebrum  and  cere- 
bellum, than  in  any  other  part  (see  p.  36).  To 
this  statement,  however,  there  is  the  striking 
exception  that  those  parts  of  the  base  of  the 
cerebrum  that  rest  upon  the  large  basal  collection 
of  the  cerebro-spinal  fluid  are  the  least  often  con- 
tused. These  parts  include  the  medulla,  the  pons, 
and  the  interpeduncular  space. 

The  brain  is  very  lavishly  supplied  with  blood- 
vessels. The  main  arterial  trunks  (vertebral  and 
internal  carotid)  are  both  rendered  tortuous  be- 
fore entering  the  skull,  with  the  object  probably  of 
diminishing  the  effects  of  the  heart's  systole  upon 
the  brain.  On  entering  they  are  almost  immedi- 
ately blended  into  an  anastomosing  circle  (circle 
of  Willis)^  which  has  the  effect  of  equalizing  the 
cerebral  circulation.  Embolism  of  the  middle 
cerebral  artery  leads  to  a  wide-spread  destruc- 
tion of  the  cerebral  cortex.  It  supplies  the  third 
frontal,  the  upper  and  middle  temporal,  the  angu- 
lar, supramarginal,  and  the  lower  two-thirds  of 
the  ascending  frontal  and  parietal  gyri.  The  only 
parts  of  the  sensori-motor  areas  which  escape  de- 
struction in  such  a  case  are  those  for  the  lower 
limbs  and  trunk.  The  anterior  cerebral  artery 
supplies  these  centres,  the  mesial  surface  of  the 
frontal  and  parietal  lobes,  and  the  adjacent  part 
of  the  cortex  on  the  outer  aspect.  The  occipital 
lobe  and  temporo-sphenoidal  convolutions  are 
supplied  by  the  posterior  cerebral  artery.  Liga- 
ture of  one  common  carotid  may  produce  no  effect 
upon  the  brain,  although  the  mortality  after  this 


48  THE    HEAD    AND    NECK  [Chap. 

operation  is  mainly  due  to  cerebral  complications. 
One  carotid  and  the  two  vertebrals  would  appear 
to  be  able  to  bring  enough  blood  to  the  brain, 
which  blood  will  be  as  evenly  distributed  as 
hitherto  by  the  circle  of  Willis.  Both  common 
carotids  have  been  ligatured,  or  one  carotid  has 
been  secured  when  its  fellow  of  the  opposite  side 
has  been  occluded  by  disease,  and  no  marked  cere- 
bral disturbances  have  followed.  In  no  case,  how- 
ever, has  the  patient  recovered  when  the  interval 
between  the  closing  of  the  two  vessels  was  less 
than  a  few  weeks.  The  vertebral  arteries  can 
carry  a  sufficient  amount  of  blood  to  the  brain 
if  only  the  strain^  be  thrown  upon  them  gradu- 
ally, and  the  brain  be  allowed  to  accommodate 
itself  slowly  to  the  change.  After  ligaturing  al] 
four  arteries  in  the  dog,  the  anastomosis  between 
the  spinal  and  cerebral  arteries  within  the  fora- 
men magnum  was  sufficient  to  maintain  life 
(Hill).  Plugging  of  any  of  the  smaller  cerebral 
arteries  by  emboli,  as  a  rule,  leads  at^  once  to  a 
marked  disastrous  result.  Such  embolism  is  met 
with  in  surgery  in  connexion  with  aneurysm  of 
the  common  carotid.  In  simply  examining  such 
aneurysms,  a  little  piece  of  the  clot  contained  in 
the  sac  has  been  detached,  has  been  carried  up 
into  the  brain,  and  has  produced  a  plugging  of 
one  of  the  cerebral  vessels.  Thus,  hemiplegia  has 
followed  upon  the  mere  examination  of  a  carotid 
aneurysm,  as  in  a  case  recorded  by  Mr.  Teale,  of 
Leeds.  Fergusson's  treatment  of  aneurysm  at  the 
root  of  the  neck,  by  displacing  the  clots  by  mani- 
pulation, has  been  abandoned  on  this  same  score. 
In  the  second  case  treated  by  manipulation  by 
this  surgeon,  one  of  subclavian  aneurysm,  para- 
lysis of  the  left  side  of  the  body  followed  at 
once  upon  the  first  handling  of  the  tumour. 

The  pulsations  of  the  brain  may  be  communi- 
cated to  any  tumours  or  collections  of  fluid  that 
reach  the  surface  of  the  brain  through  an  aper- 
ture in  the  skull.  Such  pulsations  are  synchron- 
ous  with   the    arterial    pulse,    but   the   sphygmo- 


Ill]  VESSELS    OF    THE    BRAIN  49 

graphic  tracings  of  the  cerebral  pulsations  exhibit 
also  the  "  respiratory  curve/'  conveyed  directly 
from  the  thorax  by  the  blood  within  the  veins. 
The  valve  at  the  lower  end  of  the  jugular  vein 
prevents  direct  regurgitation  of  blood  from  the 
heart  to  the  brain,  but  it  does  not  prevent  the 
transmission  of  pressure. 

Although  wounds  of  the  brain  bleed  freely, 
the  bleeding  is  checked  without  difficulty,  the 
vessels  being  capable  of  ready  contraction.  Large 
tumours  have  been  excised  from  the  cortex  of 
the  brain,  without  undue  trouble  from  haemor- 
rhage. The  terminal  branches  of  the  cerebral 
arteries  anastomose  freely  in  the  pia  mater,  but 
the  minute  arteries  which  perforate  and  supply 
the  cortex  are  terminal.  Hence  any  pressure  ap- 
plied to  the  surface  of  the  brain  will  lead  to 
anaemia  of  that  piece  of  cortex,  and,  if  the  pres- 
sure is  continued,  to  its  destruction. 

Ligature  of  a  cerebral  vein  usually  leads  to  an 
atrophy  of  the  cortex  which  it  drains  (Horsley). 
There  is  always  one — sometimes  more — anastomos- 
ing vein  on  the  surface  of  the  cerebrum,  uniting 
the  upper  with  the  lower  cerebral  veins.  The 
lower  cerebral  veins  are  four  in  number  :  three  of 
them  leave  the  temporal  and  occipital  lobes  to  end 
in  the  lateral  sinus;  the  other,  the  superficial 
Sylvian  vein,  ends  in  the  sinus  of  the  small  wing 
of  the  sphenoid.  The  temporal  and  occipital  lobes 
cannot  be  lifted  off  the  tentorium  without  rup- 
turing the  veins  joining  the  lateral  sinus. 

Nearly  all  the  veins  of  the  cerebellum  end  in 
the  lateral  sinus ;  its  arteries  are  derived  from 
vertebral  and  basilar.  Tumours  in  the  cerebel- 
lum give  rise  to  muscular  weakness  and  inco- 
ordination, giddiness,  and  loss  of  balance.  The 
vermis,  or  middle  part  of  the  cerebellum,  is  more 
directly  connected  with  bending  movements  of  the 
trunk,  while  the  lateral  lobes  are  concerned  in 
the  co-ordination  of  turning  movements — move- 
ments made  round  the  vertical  axis  of  the  trunk 
(Horsley). 


CHAPTER  IV 
THE    ORBIT    AND    EYE 

The  Orbit 

The    antero-posterior    diameter    of    the    orbit    is 
about  If   inches   (44  mm.),    its  vertical   diameter 
at    the    base    a    little    over    lj    inches    (31    mm.), 
and    its    horizontal    diameter    at   the    base    about 
lj     inches     (37     mm.).      The     diameters     of    the 
globe  are  as  follow  :    transverse,  24  mm.  ;  antero- 
posterior,  24*5  mm. ;  vertical,   23  mm.    (Brailey). 
The    eyeball    is    therefore    nearer    to    the    upper 
and    lower    margins    of    the    orbit    than    it    is 
to   the   sides,    and   the   greatest   interval   between 
the   globe    and  the   orbital   wall   is   on  the   outer 
side.     The    interior    of    the    orbit    is    most    con- 
veniently reached  by  incisions  made  to  the  outer 
side  of  the  globe,  and,  in  excision  of  the  eyeball, 
the  scissors  are  usually  introduced  on  that  side 
when  the  optic  nerve  has  to  be  divided.     In  excis- 
ing the  left  eye,    however,    it  may  be  more  con- 
venient to  divide  the  optic  nerve  from  the  inner 
side.     The  bones  forming  the  floor,  the  roof,  and 
the  inner  wall  of  the  orbital  cavity  are  very  thin, 
especially    in    the    last-named    situation.      Thus, 
foreign  bodies  thrust  intp  the  orbit  have  readily 
penetrated  into  the  cranial  cavity,  into  the  nose 
and    ethmoidal    cells,    and,    when    directed    from 
above,    into  the   antrum.      In   several   instances   a 
sharp-pointed  instrument,   such  as  the  end  of  a 
stick    or    foil,    has   been    thrust    into    the    brain 
50 


Chap.  IV]  ORBITAL    WALLS  51 

through  the  orbit,  and  has  left  but  little  external 
evidence  of  this  serious  lesion.  Nelaton  mentions 
a  case  in  which  the  internal  carotid  artery  was 
wounded  through  the  orbit.  Certain  cases  of 
pulsating  orbital  tumour  which  depend  upon  a 
communication  between  the  carotid  artery  and 
the  cavernous  sinus  have  a  traumatic  origin. 

A  reference  to  the  relations  of  the  orbital 
walls  will  show  that  a  tumour  may  readily  invade 
the  orbit  by  spreading  (1)  from  the  base  of  the  skull, 
(2)  from  the  nasal  fossae,  (3)  from  the  antrum, 
and  (4)  from  the  temporal  or  zygomatic  fossse. 
In  any  of  these  instances  the  growth  may  enter 
the  orbit  by  destroying  the  intervening  thin  layers 
of  bone,  and  in  tumours  of  the  antrum  this  is 
the  usual  mode  of  entry.  It  may,  however,  ex- 
tend more  readily  from  the  cranial  cavity  through 
the  optic  foramen  or  sphenoidal  fissure,  from  the 
nose  through  the  nasal  duct,  and  from  the  two 
fossse  named  through  the  spheno-maxillary  fis- 
sure. After  violent  blows  upon  the  temple,  blood 
has  found  its  way  into  the  orbit  through  the 
spheno-maxillary  fissure,  and  has  led  to  subcon- 
junctival ecchymosis.  Distension  of  the  frontal 
sinus  by  retained  mucus  or  pus  may  lead  to  a 
prominent  tumour  at  the  upper  and  inner  margin 
of  the  orbit,  above  the  level  of  the  tendo  oculi, 
which  may  cause  displacement  of  the  globe  down- 
wards, outwards,  and  forwards.  The  bones  of  the 
orbit  are  peculiarly  apt  to  be  the  seat  of  ivory 
exostoses,  which  may  in  time  entirely  occupy  the 
orbital  cavity. 

The  anterior  third  of  the  outer  wall  of  the 
orbit  is  separated  from  the  temporal  fossa  by 
the  malar  (Fig.  14) ;  the  posterior  two-thirds 
are  separated  by  the  great  wing  of  the  sphenoid 
from  t  the  middle  fossa  of  the  skull,  which 
contains  the  temporal  lobe.  Kronlein  removes 
intraorbital  tumours  by  opening  the  outer  wall 
of  the  orbit  in  the  temporal  fossa.  In  a  notori- 
ous case,  in  which  a  murderer  attempted  to 
commit  suicide,   the  bullet  entered  the   temporal 


52 


THE    HEAD    AND    NECK 


[Chap. 


fossa,  perforated  the  outer  wall  of  the  orbit,  and 
destroved  the  eyeball,  but  left  the  brain  un- 
touched. The  pole  of  the  temporal  lobe  is  situ- 
ated from  2  to  2*5  cm.  behind  the  outer  margin 
of  the  orbit   (see  Fig.   3,   p.   12). 

Capsule  of  Tenon.— The  best  description  of 
this   capsule   has   been   given   by    Mr.    Lockwood, 


Int. Tarsal  Liq. 
Cach.Sac 


Ext- Tarsal  LiCv 
Conjunctiva.^ 
Ext.Chcck. 


Int.  Check  Liq. 

-Capsul&ofTenon 

l/NT.  R.ECTUS 

Optic  /Iervb 

SrtEATM 


Fig.  14. — Showing  the  arrangement  of  the  capsule  of  Tenon 
and  check  ligaments. 

The  eyeball  is  turned  outwards  so  that  the  external  check  ligament 
is  taut  and  the  internal  relaxed. 


of  whose  researches  Prof.    Cunningham  provides 
the  following  resume  : — 

"  The  capsule  is  a  firm  loose  membrane  spread  over  the 
posterior  f ths  of  the  globe,  the  cornea  alone  being  free  from 
it.  In  front  it  lies  under  the  ocular  conjunctiva,  with  which 
it  is  intimately  connected,  and  it  ends  by  blending  with  that 
membrane   close   to   the   margin  of  the  cornea  (Fig.    14). 


■IV]  LIGAMENTS    OF    THE    EYE  53 

Behind  it  fuses  with  the  sheath  of  the  optic  nerve,  where  the 
latter  pierces  the  sclerotic.  The  surface  of  the  membrane 
towards  the  globe  is  smooth,  and  is  connected  to  the  eyeball 
by  some  soft  yielding  areolar  tissue.  It  thus  forms  a  kind  of 
dome  for  the  globe,  a  species  of  socket  or  bursa  in  which  it 
moves.  The  posterior  surface  of  the  capsule  is  in  contact 
with  the  orbital  fat.  The  tendons  of  the  ocular  muscles 
pierce  the  capsule  opposite  the  equator  of  the  globe  (Fig.  14). 
The  lips  of  the  openings  through  which  the  four  recti  pass 
are  prolonged  backwards  upon  the  muscles,  in  the  form  of 
sheaths,  very  much  as  the  infundibulif orm  fascia  is  prolonged 
upon  the  cord  from  the  internal  abdominal  ring.,, 

Where  the  internal  and  external  recti  per- 
forate, strong  expansions  of  the  capsule  spread 
out  to  the  inner  and  outer  walls  of  the  orbit. 
Because  these  expansions  limit  the  action  of 
the  two  recti  they  are  known  as  the  check 
ligaments  (Fig.  14).  They  allow  a  side-to- 
side  movement  of  the  cornea  to  the  extent  of 
about  45°.  The  external  check  ligament  is  the 
stronger,  and  is  attached  to  the  outer  wall  im- 
mediately behind  the  external  tarsal  ligament; 
the  attachment  of  the  internal  ligament  is  close 
behind  the  lachrymal  sac.  A  prolongation  of  the 
capsule  passes  to  the  trochlea  round  the  tendon  of 
the  superior  oblique.  The  suspensory  ligament 
of  the  eyeball  stretches  across  the  orbit  like  a 
hammock,  supporting  the  eyeball.  It  is  really 
a  thickening  of  the  under  part  of  the  capsule 
of  Tenon,  its  attachment  to  the  orbital  walls  being 
made  by  means  of  the  internal  and  external  check 
ligaments.  When  the  upper  jaw  is  removed  the 
surgeon  should  take  care  to  preserve  the  attach- 
ments of  the  suspensory  ligament.  If  these  be 
destroyed  the  eyeball  will  sink  downwards. 

The  intimate  relation  of  the  capsule  of  Tenon 
to  the  eyeball,  conjunctiva,  orbital  muscles,  and 
orbital  walls  has  to  be  kept  in  mind  where  opera- 
tions are  'undertaken  to  remedy  squint.  From 
Fig.  14  it  will  be  seen  that  after  the  tendon  of 
a  rectus  muscle  is  cut  through  as  it  lies  within 
the  capsule  of  Tenon,   the  muscle  still  possesses, 


54  THE    HEAD    AND    NECK  [Chap. 

through  the  continuity  of  its  sheath  with  the  cap- 
sule, an  attachment  to  the  eyeball  and  conjunc- 
tiva as  well  as  to  the  orbital  wall  by  the  check 
ligament.  Hence  when  the  tendon  of  a  muscle  is 
completely  cut  it  can  still  act  on  the  eyeball ;  its 
complete  retraction  is  prevented  by  the  check 
ligament. 

The  orbit  behind  Tenon's  capsule  is  occupied 
by  a  large  quantity  of  loose  fat,  in  addition  to 
the  ocular  muscles,  vessels,  and  nerves.  It  is  by 
the  absorption  of  this  fat  that  the  sunken  eye 
is  produced  in  cases  of  emaciation  and  prolonged 
illness.  This  tissue  affords  a  ready  means  for  the 
spread  of  orbital  abscess.  Such  an  abscess  may 
follow  >  injuries,  certain  ocular  inflammations, 
periostitis,  etc.,  or  may  spread  from  adjacent 
parts.  The  pus  may  occupy  the  entire  cavity,  dis- 
placing the  eyeball  forwards,  limiting  its  move- 
ments, and  causing,  by  interference  with  the  cir- 
culation, great  redness  of  the  conjunctiva  and 
swelling  of  the  lids. 

Foreign  bodies,  some  of  them  of  remarkable 
size  and  shape,  have  lodged  for  long  periods  of 
time  in  the  orbital  fat  without  causing  much 
trouble.  Thus  Lawson  reports  a  case  where  a 
piece  of  an  iron  hat-peg,  three  inches  long,  was 
embedded  in  the  orbit  for  several  days  without  the 
patient  being  aware  of  it.  A  stranger  case,  in 
some  ways,  is  that  reported  by  Furneaux  Jordan  : 
"  A  man  who  was  employed  in  threshing  became 
the  subject  of  severe  ophthalmia.  At  the  expira- 
tion of  several  weeks,  the  patient,  whilst  pressing 
his  finger  on  the  lower  eyelid,  suddenly  ejected 
from  a  comfortable  bed  of  warm  pus  a  grain  of 
wheat,  which  had  shot  forth  a  vigorous  green 
sprout. "  The  orbital  fat  affords  also  an  excellent 
nidus  for  growing  tumours. .  Fractures  of  the 
inner  wall  of  the  orbit  involving  the  nasal  fossae 
or  sinuses  may  lead  to  extensive  emphysema  of 
the  orbital  cellular  tissue.  The  air  so  introduced 
may  cause  the  globe  to  protrude,  may  limit  its 
movements,  may  spread  to  the  lids,  and  will,  in 


IV]  MUSCLES    OF    THE    ORBIT  55 

any  case,  be  increased  in  amount  by  blowing  the 
nose,  etc. 

Orbital  muscles. — The  four  recti  muscles 
end  in  thin,  flat  membranous  tendons.  The  ten- 
don of  the  external  or  internal  rectus  muscle  is 
frequently  divided  for  strabismus.  The  width  of 
the  tendons  varies  from  7  mm.  to  9  mm.  They 
are  inserted  into  the  sclerotic  near  the  cornea. 
The  internal  rectus  is  inserted  6*5  mm.  from  the 
corneal  margin,  the  external  6*8  mm.,  the  inferior 
7*2  mm.,  and  the  superior  8  mm.   (Merkel). 

While  the  internal  and  external  recti  are  pure 
internal  and  external  rotators  of  the  eyeball,  the 
superior  and  inferior  recti,  owing  to  the  line  in 


Inf.  Obliq.  Inf.  Obliq.     R.  Sup. 


R.  Int.    R.  Int. 


R.   Inf.       Sup.  Obliq.      Sup.  Obliq.      R.  Inf. 
Fig.  15. — Diagram  to  show  the  action  of  the  orbi(al  muscles 
The  arrows  show  the  direction  of  the  action  of  each  muscle. 

which  they  pull,  act  as  internal  as  well  as  up- 
ward and  downward  rotators.  Their  tendency  to 
act  as  internal  rotators  is  counterbalanced  by  the 
two  oblique  muscles,  which  serve  as  external  as 
well  as  upward  and  downward  rotators. 

The  diagram  given  in  Fig.  15  will  help  to 
make  the  actions  of  the  orbital  muscles  clearer. 
Conjugate  horizontal  movements  to  the  right  or 
left  are  executed  by  the  internal  and  external 
rectus  muscles.  When  the  cornea  is  turned 
upwards  the  muscles  in  action  are  the  inferior 
oblique  and  superior  rectus,  the  first  named  tend- 
ing to  turn  the  cornea  towards  the  temporal  as- 
pect, the  second  towards  the  nasal  aspect.  The  two 
muscles    involved    in    turning    the    cornea    down- 


56  THE    HEAD    AND    NECK  [Chap. 

wards  are  the  inferior  rectus  and  superior  oblique, 
the  first  deflecting  the  movements  towards  the 
nasal  side,  the  second  towards  the  malar  side. 
The  diagram  also  serves  to  show  the  muscles  of 
the  right  and  left  sides,  which  are  co-ordinate 
in  conjugate  movements.  Thus,  in  turning  the 
eyes  downwards  and  to  the  right,  the  superior 
oblique  of  the  right  side  acts  with  the  inferior 
rectus  of  the  left.  If  one  of  these  muscles  is 
paralysed,  then  double-vision  or  diplopia  occurs 
when  this  movement  is  carried  out. 

The  orbital  arteries  are  small,  and  seldom 
give  rise  to  trouble  when  divided  in  excising 
the  globe,  since  they  can  be  readily  compressed 
against  the  bony  walls  of  the  cavity.  Pulsating 
tumours  of  this  part  may  be  due  to^  traumatic 
aneurysms  of  one  of  the  orbital  arteries,  or  may 
depend  upon  an  arterio-venous  aneurysm  formed 
between  the  internal  carotid  artery  and  the 
cavernous  sinus.  Pressure  also  upon  the  ophthal- 
mic vein  (as  it  enters  the  sinus)  by  an  aneurysm 
of  the  internal  carotid  vessel  may  produce  all 
the  symptoms  associated  with  pulsating  orbital 
tumours.  Thrombosis  of  the  cavernous  sinus 
causes  dilatation  of  the  ophthalmic  veins  and 
proptosis. 

The  orbital  nerves  may  be  damaged  in 
wounds  of  the  orbit,  or  in  fractures  of  the  orbit 
and  of  the  base  of  the  skull.  They  may  be  pressed 
upon  by  tumours  from  various  parts,  by  aneu- 
rysms, hsemorrhagic  and  inflammatory  effusions. 
Thus,  Lawson  records  a  case  in  which  the  optic 
nerve  was  divided  by  a  stab  through  the  upper 
eyelid,  without  the  globe  being  injured,  and  with- 
out any  bone  being  fractured.  The  same  nerve 
has  also  been  completely  torn  across  in  fractures 
of  the  orbit,  and  has  been  pressed  upon  in  frac- 
tures involving  the  lesser  wing  of  the  sphenoid. 
The^  third,  fourth,  and  sixth  nerves,  and  the  first 
division  of  the  fifth,  may  be  affected  in  cases  of 
aneurysm  involving  the  internal  carotid  artery, 
where   they    lie    in   relation    with    the   cavernous 


IV]  PARALYSIS    OF    ORBITAL    NERVES  57 

sinus.  They  may  readily  be  pressed  upon,  also, 
by  any  growth  involving  the  sphenoidal  fissure, 
such  as  a  periosteal  node  springing  from  the  mar- 
gin of  the  fissure,  while  the  sixth  nerve,  from  its 
more  intimate  connexion  with  the  base  of  the 
skull,  has  been  directly  torn  across  in  a  fracture 
involving  that  part   (Prescott   Hewett). 

In  paralysis  of  the  third  nerve  there  is  droop- 
ing of  the  upper  lid  (ptosis) ;  the  eye  is  almost 
motionless,  presents  a  divergent  squint  from 
unopposed  action  of  the  external  rectus  muscle, 
and  cannot  be  moved  either  inwards,  upwards, 
or  directly  downwards.  Rotation,  in  a  direc- 
tion downwards  and  outwards,  can  still  be 
effected  by  the  superior  oblique  and  outer  rectus 
muscles.  The  pupil  is  dilated  and  fixed;  the 
power  of  accommodation  is  much  impaired,  there 
is  diplopia,  and  sometimes  a  little  protrusion  of 
the  globe  from  relaxation  of  the  recti  muscles. 
These  symptoms  refer  to  complete  paralysis  of  the 
nerve.  In  cases  of  partial  paralysis,  only  one  or 
two  of  the  above  symptoms  may  be  present. 

In  paralysis  of  the  fourth  nerve  there  is  often 
but  little  change  to  be  seen,  since  the  func- 
tion of  the  superior  oblique  muscle,  supplied  by 
this  nerve,  may,  in  part,  be  performed  vicari- 
ously. "  There  is  usually  only  very  slight  defect 
in  the  mobility  of  the  eye;  what  there  is  occurs 
chiefly;  in  the  inner  and  lower  angle  of  the  field 
of  vision;  there  is  deviation  of  the  eye  inwards 
and  upwards  on  lowering  the  object,  and  simply 
upwards  when  it  is  turned  far  towards  the  healthy 
side  "  (Erb).  In  any  case  there  will  be  diplopia, 
especially  in  certain  positions  of  the  globe. 

In  paralysis  of  the  sixth  nerve  there  is  con- 
vergent strabismus,  with  consequent  diplopia, 
and  an  inability  to  rotate  the  eye  directly  out- 
wards. Paralysis  of  the  sixth  nerve  may  be  ac- 
companied by  paralysis  of  the  nerve  to  the  in- 
ternal rectus  of  the  opposite  side,  giving  rise  to 
conjugate  deviation  of  the  eyes.  Such  a  condi- 
tion indicates  a  lesion  in  the  nucleus  of  the  sixth 


58  THE    HEAD    AND    NECK  [Chap. 

nerve,  for  although  the  fibres  for  the  internal 
rectus  pass  out  with  the  third  nerve  they  take 
their  origin  with  the  sixth. 

Sometimes  all  the  oculo-motor  nerves  of  the 
eye  are  paralysed,  and  in  such  cases  the  lesion 
is  ■  probably  situated  either  at  their  nuclei  of 
origin  or  at  the  cavernous  sinus,  in  the  wall  of 
which  the  nerves  lie  close  together. 

In  paralysis  of  the  first  division  of  the  fifth 
there  is  a  loss  of  sensation  in  all  the  conjunctiva, 
except  such  as  covers  the  lower  lid  (supplied  by 
the  palpebral  branch  of  the  infraorbital  nerve), 
loss  of  sensation  in  the  globe,  and  in  skin  sup- 
plied by  the  supratrochlear  and  supraorbital 
nerves,  and  in  the  mucous  and  cutaneous  surfaces 
supplied  by  the  nasal  nerve.  The  area  of  anaes- 
thesia is  much  less  than  the  anatomical  distri- 
bution of  the  nerve,  owing  to  the  extent  to  which 
cutaneous  nerves  overlap.  No  reflex  movements 
(winking)  follow  upon  irritation  of  the  conjunc- 
tiva, although  the  patient  can  be  made  to  wink 
on  exposing  the  eye  to  a  strong  light,  the  optic 
nerve  in  this  case  transmitting  the  impression  to 
the  facial  nerve.  Sneezing  also  cannot  be  ex- 
cited by  irritating  the  mucous  membrane  in  the 
anterior  part  of  the  nose.  Destructive  ulceration 
of  the  cornea  may  follow  this  paralysis,  due 
partly  to  damage  to  the  trophic  branches  con- 
tained in  the  paralysed  nerve,  partly  to  the  anaes- 
thesia which  renders  the  part  readily  injured,  and 
partly  to  the  loss  of  the  reflex  effect  of  the  sensory 
nerves  upon^  the  calibre  of  the  blood-vessels, 
whereby  the  inflammation  is  permitted  to  go  un- 
controlled  (Nettleship). 

In  paralysis  of  the  cervical  sympathetic  there 
is  narrowing  of  the  palpebral  fissure  from  some 
drooping  of  the  upper  lid,  apparent  recession 
of  the  globe  within  the  orbit,  and  some  narrow- 
ing of  the  pupil  from  paralysis  of  the  dilator 
muscle  of  the  iris,  which  muscle  is  supplied  by  the 
sympathetic.  The  drooping  of  the  upper  lid  may 
be  explained  by  the  fact  that  each  eyelid  contains 


IV]  THE    EYE  59 

a  layer  of  unstriated  muscle  fibre.  That  in  the 
upper  lid  arises  from  the  under  surface  of  the 
levator  palpebrse,  and  is  attached  to  the  tarsal 
cartilage  near  its  upper  margin  (Fig.  18,  p.  76). 
This  layer  of  muscle,  which,  when  in  action, 
would  keep  up  the  lid,  is  under  the  influence  of 
the  cervical  sympathetic.  The  recession  of  the 
globe  is  supposed  by  some  to  be  due  to  paralysis 
of  the  orbitalis  muscle  of  H.  Muller.  This  muscle 
bridges  over  the  spheno-maxillary  fissure,  is  com- 
posed of  unstriated  fibres,  and  is  innervated  by  the 
sympathetic.  Contraction  of  the  muscle  (as  pro- 
duced by  stimulation  of  the  cervical  sympathetic 
in  animals)  causes  protrusion  of  the  globe,  while 
section  of  the  sympathetic  in  the  neck  produces 
retraction  of  the  eyeball  (Claude  Bernard).  No 
changes  are  observed  in  the  calibre  of  the  blood- 
vessels of  the  globe.  The  non-striated  muscle 
maintains  the  intraorbital  pressure,  and  thus 
assists  in  the  return  of  blood  from  the  ophthalmic 
veins.  In  animals  such  as  the  ox,  in  which  the 
veins  of  the  orbit  become  dilated  when  the  head 
is  carried  low,  as  in  browsing,  this  musculature 
attains  a  great  development. 

The  Globe 

The  cornea. — The  thickness  of  the  cornea 
varies  from  0'9  mm.  in  the  central  parts  to 
1*1  mm.  at  the  periphery.  One  is  apt  to  be  a 
little  deceived  as  to  its  thickness,  and  on  intro- 
ducing a  knife  into  the  cornea,  the  instrument, 
if  not  entered  atthe  proper  angle,  may  be  thrust 
for  some  little  distance  among  the  laminae  of  the 
part.  In  front  the  cornea  is  covered  by  stratified 
epithelium.  When  this  layer  has  been  removed 
by  abrasion,  a  white  deposit  of  lead  salts  may 
take  place  in  the  exposed  corneal  tissue  in  cases 
where  lead  lotions  are  used.  The  bulk  of  the 
cornea  is  made  up  of  a  great  number  of  fibrous 
lamellae,  between  which  are  anastomosing  cell 
spaces  containing  the  corneal  corpuscles.     If  the 


60 


THE    HEAD    AND    NECK 


[Chap. 


nczzle  of  a  fine  syringe  be  thrust  into  the  corneal 
tissue,  the  network  of  cell  spaces  can  be  filled 
with  injection  (Recklinghausen's  canals).  When 
suppuration  takes  place  within  the  proper 
corneal  tissue,  it  is  probably  along  these  canals, 
modified  by  inflammation,  that  the  pus  spreads, 
thus  producing  onyx.  The  cornea  contains  no 
trace  of  blood-vessels,  except  at  its  extreme  peri- 


Fig.     16. — Horizontal  section   of    the    globe    through    the 
middle. 

a,  Cornea  :  &,  sclerotic  ;  c,  choroid  ;  <7,  retina  ;  e,  lens  ;/,  iris  ;  g,  ciliary 
process  and  muscle  ;  h,  canal  of  Schlemm. 


phery,  where  the  capillaries  of  the  sclerotic  and 
conjunctiva  end  in  loops.  This  lack  of  a  direct 
blood  supply  renders  the  cornea  prone  to  inflame 
spontaneously  in  the  cachectic  and  ill-nourished. 
When  inflamed,  the  tissue  always  becomes  opaque. 
In  the  affection  known  as  interstitial  keratitis, 
blood-vessels  from  the  arteries  of  the  margin  of 
the    cornea    penetrate    into    the    substance   of   the 


IVJ  THE    CORNEA  61 

cornea  for  some  distance.  As  these  vessels  are 
some  little  way  below  the  surface,  and  are 
covered  by  the  hazy  corneal  tissue  that  is  the  re- 
sult of  the  disease,  their  scarlet  colour  is  much 
toned  down,  and  a  strand  of  such  vessels  is  called 
a  "salmon  patch."  In  the  condition  known  as 
pannus,  the  cornea  appears  to  be  vascularized ; 
but  here,  owing  to  continued  irritation,  vessels, 
derived  from  the  neighbouring  conjunctival 
arteries,  pass  over  the  cornea  just  beneath  its 
epithelial  covering,  leaving  the  cornea  proper  as 
bloodless  as  ever.  The  term  arcus  senilis  is  ap- 
plied to  two  narrow  white  crescents  that  appear 
at  the  periphery  of  the  cornea,  just  within  its 
margin,  in  the  aged,  and  in  certain  morbid  con- 
ditions. The  crescents  are  placed  at  the  upper 
and  lower  margins,  and  their  points  meet  midway 
on  either  side  of  the  cornea.  They  are  due  to 
fatty  degeneration  of  the  corneal  tissue,  and  the 
change  is  most  marked  in  the  layers  of  the  cornea 
just  beneath  the  anterior  elastic  lamina,  i.e.  in 
the  part  most  influenced  by  the  marginal  blood- 
vessels. In  spite  of  its  lack  of  a  direct  blood 
supply,  wounds  of  the  cornea  heal  kindly. 

The  cornea  is  very  lavishly  supplied  with 
nerves,  estimated  to  be  from  forty  to  forty-five 
in  number.  They  are  derived  from  the  ciliary 
nerves,  enter  the  cornea  through  the  fore  part 
of  the  sclerotic,  and  are  distributed  to  every 
part  of  the  tunic.  In  glaucoma,  a  disease  of 
which  the  phenomena  depend  upon  greatly  in- 
creased intraocular  pressure,  the  cornea  becomes 
anaesthetic.  This  depends  upon  the  pressure  to 
which  the  ciliary  nerves  are  exposed  before  their 
branches  reach  the  cornea.  (See  also  Nerve 
Supply  of  the   Eyeball,    p.   66.) 

Sclerotic,  choroid,  and  iris.—  The  sclerotic 
is  thickest  behind,  and  thinnest  about  J  of  an 
inch  from  the  cornea.  When  the  globe  is  rup- 
tured by  violence  it  is  the  sclerotic  that  most 
commonly  yields,  the  rent  being  usually  a 
little  way   from  the  cornea,   i.e.   in  or  about  the 


62  THE    HEAD    AND    NECK  [Chap, 

thinnest  part  of  the  tunic.  A  rupture  of  the 
cornea  alone  from  violence  is  not  common.  The 
sclerotic  may  be  ruptured  while  the  lax  conjunc- 
tiva over  it  remains  untorn.  In  such  a  case  the 
lens  may  escape  through  the  rent  in  the  sclerotic, 
and  be  found  under  the  conjunctiva.  At  the  point 
of  penetration  of  the  optic  nerve  the  sclerotic  is 
thin,  and  pierced  by  numerous  holes  for  the  pas- 
sage of  nerve  bundles.  This  weakened  portion, 
the  lamina  cribrosa,  plays  an  important  part  in 
glaucoma  (p.  74).  It  gjives  the  stippled  appear- 
ance to  the  optic  papilla.  Brailey  states  that 
the  lateral  parts  of  the  sclerotic  are  thinner  than 
the  upper  and  lower  segments,  the  inferior  part 
being  the  thickest  and  the  external  wall  the  thin- 
nest. It  happens,  therefore,  that  under  the  influ- 
ence of  intraocular  pressure  the  eye  expands  more 
laterally  than  in  the  vertical  direction.  It  is 
mainly  to  the  tenseness  and  unyielding  character 
of  the  sclerotic  that  must  be  ascribed  the  severe 
pain  (due  to  pressure  on  nerves)  experienced  in 
those  eye  affections  associated  with  increased  intra- 
ocular tension  (glaucoma,  etc.). 

The  choroid  is  the  vascular  tunic  of  the  globe, 
and  carries  its  main  blood-vessels.  Between  the 
choroid  and  sclerotic  are  two  thin  membranes,  the 
lamina  suprachoroidea  and  lamina  fusca,  which 
are  separated^  from  one  another  by  a  lymph 
space.  In  injuries  to  the  globe,  therefore,  ex- 
tensive bleeding  may  take  place  between  these  two 
coats,  and  indeed  a  like  haemorrhage  may  be  the 
result  simply  of  a  sudden  diminution  in  the 
ocular  tension  produced  by  such  an  operation  as 
iridectomy  or  cataract  extraction.  The  choroid 
alone  has  been  ruptured  (usually  at  its  posterior 
part)  as  the  result  of  a,  blow  upon  the  front  of 
the  eye.  The  choroid  is  one  of  the  few  parts  of 
the  body  that  may  be  the  seat  of  melanotic 
growths.  These  growths  are  sarcomatous  tumours 
containing  a  large  amount  of  pigment,  and  occur 
only  where  pigment  cells  are  found.  In  the 
choroid  coat  pigment  cells  are  very  abundant. 


IV]  THE    IRIS  63 

The  iris  is,  from  its  great  vascularity,  very 
easily  inflamed.  From  its  relations  to  the  cornea 
and  sclerotic  it  happens  that  inflammation  in  those 
tunics  can  spread  without  difficulty  to  the  iris. 
On  the  other  hand,  the  vessels  of  the^  iris  and 
choroid  are  so  intimately  related  that  inflamma- 
tions set  up  in  the  iris  itself  have  every  induce- 
ment to  spread  to  the  choroidal  tunic.  When  the 
iris  is  inflamed  its  colour  becomes  altered,  owing 
to  the  congestion  of  the  part  and  to  the  effusion  of 
lymph  and  serum  that  takes  place  in  its  substance. 
The  swelling  to  which  it  becomes  subject,  together 
with  the  effusion,  produce  a  blurring  of  its  delicate 
reticulated  structure,  as  seen  through  the  cornea. 
Owing  also  to  the  swollen  condition  of  the  little 
membrane,  the  pupil  becomes  encroached  on, 
and  appears  to  be  contracted,  while  the  move- 
ments of  the  membrane  are  necessarily  rendered 
very  sluggish.  If  it  be  remembered  that  part 
of  the  posterior  surface  of  the  iris  is  in  actual 
contact  with  the  lens  capsule,  it  will  be  understood 
that  inflammatory  adhesions  may  readily  take 
place  between  the  two  parts  (Fig.  16).  After  iritis, 
therefore,  it JUj  common  to  find  the  posterior  sur- 
face of  the  iris  (most  often  its  pupillary  margin) 
adherent  to  the  lens  capsule  by  bands  of  lymph, 
either  entirely  or  in  one  or  more^  different  points. 
Such  adhesions  constitute^  posterior  synechias,  the 
term  anterior  synechise  being  applied  to  adhesions 
between  the  iris  and  the  cornea.  In  iritis  also 
the^  lens  may  become  involved,  and  the  con- 
dition of  secondary  or  inflammatory  cataract  be 
produced. 

The  iris  is  not  very  closely  attached  at  its 
insertion  (Fig.  17).  Thus,  in  the  case  of  injury 
to  the  eye,  it  may  be  torn  more  or  less  from 
its  attachments  without  any  damage  being  done 
to  the  other  tunics.  The  iris  has  been  com- 
pletely torn  away  in  a  few  instances,  and  has 
escaped  through  a  wound  of  the  globe.  The 
ciliary  processes  have  been  thus  exposed.  Con- 
genital   absence    of    the    iris    has    been    recorded. 


64  THE    HEAD    AND    NECK  [Chap. 

In  cases  of  penetrating  wounds  of  the  cornea  the 
iris  is  easily  prolapsed.  It  is  so  delicate  and  yield- 
ing a  membrane  that  in  performing  iridectomy  the 
necessary  piece  of  the  iris  can  be  seized  and  pulled 
out  through  the  corneal  incision  without  offering 
sensible  resistance.  The  membrane  also  derives 
much  support  from  its  contact  with  the  lens,  for 
in  cases  where  the  lens  has  been  displaced  into  the 
vitreous,  or  has  been  removed  by  operation,  the 
iris  is  observed  to  be  tremulous  when  the  globe  is 
moved.  Although  very  vascular,  the  iris  seldom 
bleeds  much  when  cut,  a  circumstance  that  is  pro- 
bably due  to  the  contraction  of  the  muscular  fibres 
that  exist  so  plentifully  within  it.  Sometimes  the 
iris  presents  in  its  substance  a  congenital  gap  that 
runs  froin  the  pupil  downwards  and  a  little  in- 
wards. This  condition  is  known  as  coloboma  iridis, 
and  is  due  to  the  persistence  of  the  "  choroidal 
cleft "  formed  during  development  of  the  optic 
cup.  In  other  cases  there  can  be  seen,  stretch- 
ing across  the  pupil,  some  shreds  of  the  pupillary 
membrane.  Normally  this  membrane,  which  is  ap- 
parent for  a  few  days  after  birth  in  some  animals, 
is  entirely  absorbed  before  birth. 

It  will  now  be  convenient  to  take  note  of  the 
blood  and  nerve  supply  of  the  globe. 

Blood  supply  of  the  eyeball. —  1.  The 
short  ciliary  arteries  (from  the  ophthalmic)  pierce 
the  sclerotic  close  to  the  optic  nerve,  run  some 
little  way  in  the  outer  coat  of  the  choroid,  and  then 
break  up  into  a  capillary  plexus  that  makes  up  the 
main  part  of  the  inner  choroidal  coat.  In  front  this 
plexus  gives  some  vessels  to  the  ciliary  processes. 
The  veins  from  these  vessels  are  disposed  in  curves 
as  they  converge  to  four  or  five  main  trunks  (venae 
vorticosse),  which  pierce  the  Sclerotic  midway  be- 
tween the  cornea  and  the  optic  nerve.  In  the 
choroid  they  lie  externally  to  the  arteries. 

2.  The  two  long  ciliary  t  arteries  (from  the 
ophthalmic  pierce  the  sclerotic  to  the  outer  side 
of  the  optic  nerve  and  run  forwards,  one  on  either 
side,  until  they  reach  the  ciliary  region,  where  they 


IV]  VESSELS    OF    THE    EYEBALL  65 

break  up  into  branches  that,  by  anastomosing, 
form  a  vascular  circle  about  the  periphery  of  the 
iris  (the  circulus  major).  From  this  circle  some 
branches  pass  to  the  ciliary  muscle,  while  the  rest 
run  in  the  iris  in  a  converging  manner  towards  the 
pupil,  and  at  the  margin  of  the  pupil  form  a 
second  circle  (the  circulus  minor). 

3.  The  anterior  ciliary  arteries  (from  the  mus- 
cular and  lachrymal  branches  of  the  ophthalmic) 
pierce  the  sclerotic  (perforating  branches)  about 
2-3  mm.  behind  the  cornea,  join  the  circulus 
major,  and  give  off  branches  to  the  ciliary  pro- 
cesses, where  they  form  copious  anastomosing 
loops.  These  arteries  lie  in  the  subconjunctival 
tissue.  Their  episcleral  or  non-perforating  branches 
are  very  small  and  numerous,  and  are  invisible 
in  the  normal  state  of  the  eye.  In  inflammation 
of  the, iris  and  adjacent  parts,  however,  these  ves- 
sels appear  as  a  narrow  pink  zone  of  fine  vessels 
round  the  margin  of  the  cornea,  that  run  nearly 
parallel  to  one  another,  are  very  closely  set,  and 
do  not  move  with  the  conjunctiva.  This  zone  is 
known  as  the  zone  of  ciliary  congestion,  or  the  cir- 
cumcorneal  zone. 

4.  The  vessels  of  the  conjunctiva  are  derived 
from  the  lachrymal  and  the  two  palpebral  arteries. 
These  vessels,  in  cases  of  inflammation,  are  readily 
distinguished  from  those  last  described.  They  are 
of  comparatively  large  size,  are  tortuous,  are  of  a 
bright  brick-red  colour,  can  be  easily  moved  with 
the  conjunctiva,  and  as  easily  emptied  of  their 
blood  by  pressure.  The  differences  presented  by 
these  two  sets  of  vessels  serve  in  one  way  to  dis- 
tinguish inflammation  of  the  conjunctiva  from  that 
involving  deeper  parts.  The  conjunctival  vessels 
around  the  margin  of  the  cornea  form  a  closer 
plexus  of  anastomosing  capillary  loops,  which  be- 
come congested  in  severe  superficial  inflammation 
of  the  cornea,  and  may  then  form  a  zone  around 
the  margin  of  the  cornea,  which  can,  however,  be 
distinguished  from  the  "  ciliary  zone  "  by  the 
general  characters  just  named.     The  retina  has  a 

D 


66  THE    HEAD    AND    NECK  [Chap. 

vascular  system^  of  its  own,  supplied  through  the 
arteria  centralis  retinae,  which  is  nowhere  in 
direct  communication  with  the  choroidal  vessels, 
except  just  at  the  entrance  of  the  optic  nerve. 
Indeed,  the  outer  layers  of  the  retina  which  are  in 
relation  with  the  choroid  coat  are  entirely  destitute 
of  vessels.  Thus,  when  the  central  artery  of  the 
retina  becomes  plugged,  sudden  blindness  follows, 
and  as  the  meagre  collateral  circulation  that  is 
established  by  the  minute  anastomoses  about  the 
entrance  of  the  nerve  is  quite  insufficient,  the  re- 
tina soon  becomes  cedematous.  A  permanent  plug- 
ging of  the  central  artery  means,  therefore,  a  prac- 
tical extinction  of  the  vascular  system  of  the  re- 
tina. In  some  cases  of  embolism,  only  a  branch  of 
the  retinal  artery  is  plugged,  the  patient  retaining 
vision  except  in  that  par.t  of  the  retina  supplied 
by  the  branch.  The  fovea  centralis,  the  centre  of 
acute  vision,  receives  twigs  from  both  the  superior 
and  inferior  temporal  branches  of  the  arteria 
centralis  retinae. 

In  cases  of  haemorrhage  between  the  choroid 
and  retina  the  blood  must  come  from  the  choroidal 
vessels ;  and  in  haemorrhage  into  the  vitreous, 
which  often  follows  injury,  the  blood  may  be  de- 
rived from  the  retinal  vessels,  since  they  run  in  the 
inner  layers  of  that  membrane,  or  from  the  vessels 
in  the  ciliary  region. 

Nerve  supply  of  the  eyeball. — l.  The  cili- 
ary nerves  derived  from  the  lenticular  ganglion 
and  the  nasal  nerve  pierce  the  sclerotic  close  to  the 
optic  nerve,  and  pass  forwards  between  the  sclero- 
tic and  the  choroid,  supplying  those  parts.  They 
enter  the  ciliary  muscle,  form  a  plexus  about  the 
periphery  of  the  iris,  and  then  send  fibres  into 
the  iris,  which  form  a  fine  plexus  as  far  as 
the  pupil.  They  send  branches  through  the  fore 
part  of  the  sclerotic  to  the  cornea.  Thus  the  eye- 
ball obtains  through  these  nerves  its  sensory  fibres 
from  the  nasal  branch  of  the  first  division  of  the 
fifth,  its  motor  fibres  for  the  ciliary  muscle  and 
sphincter  iridis  from  the  third  nerve,   and  many 


IVj       NERVES  OF  THE  EYEBALL        67 

sympathetic  fibres,   among  which   are   those  that 
supply  the  dilator  muscle  of  the  iris. 

2.  The  conjunctiva  is  supplied  by  four  nerves  : 
above,  the  supratrochlear;  inner  side,  the  infra- 
trochlear;  outer  side,  the  lachrymal  (all  branches 
of  the  first  division  of  the  fifth) ;  below,  the  palpe- 
bral branches  of  the  second  division  of  the  fifth. 
As  the  ciliary  nerves  pass  forwards  between  the 
choroid  and  the  sclerotic,  it  will  be  seen  that  they 
are  readily  exposed  to  injurious  pressure  against 
the  unyielding  sclerotic  in  cases  of  increased  intra- 
ocular tension. 

The  sensation  of  the  globe  itself  is  derived  solely 
from  the  first  division  of  the  fifth.  In  inflammatory 
affections  of  the  globe,  as  in  corneitis  or  iritis,  be- 
sides the  pain  actually  felt  in  the  eye,  there  is 
pain  referred  along  other  branches  of  the  first 
division  of  the  fifth.  The  explanation  of  this  fact 
has  to  be  sought  for  in  the  common  origin  of 
the  ophthalmic  division  from  the  upper  sensory 
nucleus  of  the  fifth  nerve  in  the  floor  of  the  fourth 
ventricle.  Not  only  are  the  nerve  cells  connected 
with  the  eyeball  disturbed,  but  the  neighbouring 
cells  also  are  affected,  and  by  a  psychical  error 
the  pain  is  reflected  along  the  nerves  with  which 
they  are  connected.  There  is  pain  over  the  fore- 
head along  the  supratrochlear,  the  supraorbital, 
and  the  lachrymal  branches  (circumorbital  pain), 
and  pain  down  the  side  of  the  nose  following 
the  nasal  nerve.  Or  the  pain  may  spread  to 
the  second  division  of  the  fifth,  and  discom- 
fort be  felt  in  the  temporal  region  (orbital 
branch  of  second  division),  or  be  referred  to 
the  upper  jaw  and  teeth.  These  affections  are 
associated  also  with  much  lachrymation,  the 
lachrymal  gland  being  also  supplied  through  the 
first  division  of  the  fifth.  Photophobia,  or  intoler- 
ance of  light,  is  common  in  inflammatory  affec- 
tions of  the  eye.  In  this  condition  there  is  spasm 
of  the  orbicular  muscle,  keeping  the  eye  closed, 
or  closing  it  on  the  least  exposure  to  irritation. 
Although  the  orbicular  muscle  is  supplied  by  the 


68  THE    HEAD    AND    NECK  [Chap. 

facial  nerve,  its  nerve  fibres  are  derived,  not  from 
the  nucleus  of  the  seventh  but  from  the  oculo- 
motor nucleus,  situated  near  the  upper  sensory 
nucleus  of  the  fifth,  and  connected  with  it  by 
reflex  paths.  Photophobia  is  most  marked  in 
superficial  affections  of  the  cornea,  and  is  often 
much  benefited  by  a  seton  in  the  temporal  region. 
Inflammation  of  the  iris  and  glaucoma  are  accom- 
panied by  hyperesthesia  and  referred  pains  over 
the  outer  frontal  and  anterior  temporal  areas 
(Head).  The  nerve  centres  for  the  skin  of  this 
region  and  the  eyeball  are  closely  connected,  a 
relationship  which  may  explain  the  application 
of  counter-irritation  to  the  temples  in  eye  disease. 
Inflammation  of  the  cornea  gives  rise  to  no 
referred  pains  (Head).  Strain  of  the  ciliary 
muscle,  which  occurs  with  errors  of  refraction,  is 
one  of  the  commonest  causes  of  headache  leading 
to  referred  pains  and  areas  of  hyperesthesia  over 
the  midorbital   region  of  the   forehead. 

The  relations  between  the  nasal  nerve  and  the 
orbital  contents  receive  many  illustrations  in  prac- 
tice. Thus,  if  the  front  of  the  nose  be  struck,  or 
the  skin  over  its  lower  part  be  irritated,  as  by 
squeezing  a  painful  boil,  profuse  lachrymation  will 
frequently  be  produced.  Snuff,  too,  by  stimulating 
the  nasal  branch  of  the  ophthalmic  nerve,  often 
makes  the  eyes  of  the  uninitiated  to  water ;  and 
it  is  well  known  that  there  are  many  disturb- 
ances about  the  nose,  and  the  anterior  part  of  the 
nasal  fossae,  that  can  "make  the  eyes  water.' ' 
Herpes  zoster  often  provides  a  remarkable  illus- 
tration of  the  intimate  relation  between  the  nasal 
nerve  and  the  eye.  In  this  affection,  when  the 
regions  of  the  supraorbital  and  supratrochlear 
branches  of  the  first  division  are  alone  implicated, 
the  eye  is  usually  unaffected;  but  when  the  erup- 
tion extends  over  the  part  supplied  by  the  nasal 
nerve,  i.e.  runs  down  the  side  of  the  nose,  then 
there  is  very  commonly  some  inflammation  of  the 
eyeball. 

Dangerous  area   of  the    eye.— Penetrating 


IV]      DANGER  AREA  OF  THE  EYE       69 

wounds  of  the  cornea  alone,  or  of  the  sclerotic 
alone,  behind  the  ciliary  region,  are  by  no  means 
serious;  but  wounds  involving  the  ciliary  body, 
or  its  immediate  vicinity,  are  apt  to  assume  the 
gravest  characters.  Inflammation  in  the  ciliary 
region  is  peculiarly  obnoxious,  on  account  of  the 
important  vascular  and  nerve  anastomoses  that 
take  place  in  the  part.  Indeed,  as  regards  blood 
and  nerve  supply,  there  is  no  more  important 
district  in  the  eyeball.  From  the  ciliary  body 
also  inflammations  can  spread,  more  or  less 
directly,  to  the  cornea,  iris,  choroid,  vitreous,  and 
retina.  Plastic,  or  purulent,  inflammation  of  the 
ciliary  body,  after  injury,  is  the  usual  starting- 
point  of  sympathetic  ophthalmia.  In  this  ter- 
rible affection  destructive  inflammation  is  set  up 
in  the  sound  eye,  which  is,  however,  not  usually 
involved  until  two  or  three  months  after  the  other 
eye  has  been  injured.  "  Although  at  present  the 
exact  nature  of  the  process  which  causes  sym- 
pathetic inflammation  is  unknown,  and  though 
its  path  has  not  been  fully  traced  out,  it  is  cer- 
tain (1)  that  the  change  starts  from  the  region 
most  richly  supplied  by  branches  of  the  ciliary 
nerves,  viz.  the  ciliary  body  and  iris;  (2)  that  its 
first  effects  are  generally  seen  in  the  same  part  of 
the  sympathizing  eye ;  (3)  that  the  exciting  eye  has 
nearly  always  been  wounded,  and  in  its  anterior 
part,  and  that  decided  plastic  inflammation  of  its 
uveal  tract  is  always  present;  (4)  that  inflamma- 
tory changes  have  in  some  cases  been  found  in  the 
ciliary  nerves  and  optic  nerve  of  the  exciting 
eye  ;;  (Nettleship).  It  is  now  generally  believed 
that  the  sound  eye  is  directly  infected  from  the 
diseased  one.  The  subarachnoid  spaces  which  sur- 
round the  optic  nerves  are  in  continuity  at  the 
chiasma,  and  offer  a  path  whereby  infection  may 
spread  from  one  eye  to  the  other. 

The  lens  measures  J  of  an  inch  from  side  to 
side,  and  I  of  an  inch  from  before  backwards. 
All  through  life  it  slowly  increases  in  size.  It, 
together   with   its   capsule,    is    in    all    parts   per- 


70  THE    HEAD    AND    NECK  [Chap. 

fectly  transparent  and  perfectly  non-vascular. 
The  manner  in  which  the  lens  is  maintained  in 
position  is  shown  in  Fig.  17.  The  circumference 
of  the  lens  is  fixed  to  the  ciliary  processes  by 
a  system  of  fine,  transparent,  radial  fibres  (the 
suspensory  ligament  of  the  lens),  some  of  which 
pass  in  front  of  the  lens,  while  others  pass 
behind  it,  thus  forming  a  sac  or  capsule  for  the 
lens.  On  the  ciliary  processes  the  radial  fibres 
of  the  suspensory  ligament  become  continuous 
with  the  transparent  capsule  of  the  vitreous 
humour — the  hyaloid  membrane.  The  lens  may 
easily  be  loosened  or  displaced  by  partial  rupture 
of  its  suspensory  ligament,  and  may  find  its  way 
into  the  anterior  chamber,  or,  more  commonly, 
back  into  the  vitreous.  The  lens,  if  disturbed, 
may  swell,  and  by  the  pressure  thus  exercised 
cause  great  damage  to  the  important  structures 
adjacent  to  it.  The  capsule  is  very  brittle  and 
elastic,  and  when  torn  its  edges  curl  outwards. 
It  is  lacerated  in  the  usual  operations  for  cataract, 
and  may  be  ruptured  by  many  forms  of  violence 
applied  to  the  eyeball.  ^ "  In  one  form  of  cataract 
operation  the  capsule  is  removed  with  the  lens, 
the  vitreous  being  retained  in  position  by  the 
hyaloid  membrane  which  lies  behind  the  capsule 
of  the  lens"  (Lieut.-Colonel  H.  Smith).  When  the 
capsule  is  wounded  the  aqueous  humour  enters, 
and  is  imbibed  by  the  lens  fibres,  which  in  conse- 
quence swell  up  and  become  opaque,  thus  produc- 
ing a  traumatic  cataract.  In  the  various  forms  of 
cataract  the  whole  lens,  or,  more  commonly,  some 
portion  of  it,  becomes  the  seat  of  opacity.  This 
often  commences  in  the  nucleus,  and  for  a  long 
while  remains  limited  to  that  part;  or  it  may 
first  involve  the  cortex,  and  in  such  a  case 
the  opacity  takes  the  form  of  a  series  of  streaks 
that  point  towards  the  axis  of  the  lens,  and 
are  dependent  upon  the  arrangement  of  the  lens 
fibres. 

Of  the  retina    it  is  only  necessary^  to  observe 
that  its  connexion   with  the  choroid  is  so  slight 


IV]  THE    EETINA  71 

that  it  may  easily  be  detached  from  that  mem- 
brane by  hemorrhagic  or  other  effusions,  and  may 
indeed  be  so  detached  by  a  simple  blow  upon  the 
globe.  Even  when  extensively  detached  it  remains, 
however,  as  a  rule,  attached  at  both  the  optic  disc 
and  the  or  a  serrata. 

The  length  of  the  optic  nerve  within  the  orbit 
is  28-30  mm.  As  it  passes  from  the  brain  it 
receives  its  perineural  sheath  from  the  pia 
mater,  and,  in  addition,  two  other  sheaths  :  an 
outer  from  the  dura  mater,  and  an  inner  from 
the  arachnoid.  These  sheaths  remain  distinct  and 
separate,  and  the  two  spaces  enclosed  may  be  in- 
jected, the  outer  from  the  subdural,  the  inner  from 
the  subarachnoid  space.  Thus  inflammatory  affec- 
tions of  the  cerebral  meninges  can  readily  extend 
along  the  optic  nerve  to  the  optic  disc  through 
these  spaces  in  the  nerve  sheath,  while  in  cases  of 
intracranial  disease  other  than  meningeal  the 
mischief  may  extend  from  the  brain  to  the  disc 
along  the  interstitial  connective  tissue  in  the  nerve. 
These  connexions  may  serve  in  part  to  explain  the 
frequent  association  of  optic  neuritis  with  intra- 
cranial disease.  As  the  nerve  leaves^  the  skull  in 
the  optic  foramen  it  is  in  contact  with  the  outer 
wall  of  ^  the  sphenoidal  sinus,  or,  if  that  sinus 
be  relatively  small,  with  the  posterior  ethmoidal 
cells.  In  suppuration  of  these  spaces  infection 
may  spread  to  the  optic  nerve,  and  thus  set  up 
optic  neuritis.  Optic  neuritis  usually  implies 
that  the  optic  disc  or  papilla  is  inflamed,  but  in 
exceptional  cases  the  changes  are  limited  to  that 
part  of  the  nerve  behind  the  globe  (retrobulbar 
neuritis). 

Aqueous  and  vitreous  humours.— The 
aqueous  fills  the  space  between  the  capsule  and 
suspensory  ligament  of  the  lens  and  the  cornea. 
The  iris  divides  this  space  into  two  parts,  the  an- 
terior and  posterior  chambers.  Since,  however,  the 
iris  is  largely  in  actual  contact  with  the  lens,  it 
happens  that .  the  posterior  chamber  is  repre- 
sented by   a  little   angular   interval   between   the 


72 


THE    HEAD    AND    NECK 


[Chap. 


iris,  the  ciliary  processes,  and  the  suspensory 
ligament  of  the  lens  (Fig.  17).  The  depth  of  the 
anterior  chamber  is  3*6  mm.  The  inner  stratum 
of  the  cornea,  as  it  becomes  continuous  with 
the  sclerotic,  splits  up  into  fibres  which  pass  to 
(1)  the  sclerotic,  (2)  the  ciliary  muscle,  (3)  the 
ciliary  processes.  The  fibres  form  the  ligamentum 
pectinatum,   and  the   intervals  between   its  fibres 


Canal  of  Schlemm 
Pectinate  Liq. 
Ciliary  Muse. 


(f —  lens 


Fig.     17. — Ligamentum    pectinatum,  spaces    of    Fontana, 
ciliary  muscle,  and  capsule  of  the  lens.     (After  Fuchs.) 


are  known  as  the  spaces  of  Fontana.  They  are 
filled  by  the  aqueous  humour.  These  spaces  in 
their  turn  communicate  with  a  venous  circular 
canal  situate  in  the  sclerotic  close  to  its  junction 
with  the  cornea,  and  known  as  the  canal  of 
Schlemm  (Fig.  17).  This  canal  is  in  communica- 
tion with  the  veins  of  the  anterior  part  of  the 
sclerotic,  ciliary  processes  and  iris.  The  aqueous 
humour  passes  from  the  spaces  of  Fontana  into 


IV]       xlQUEOUS    AND    VITREOUS    HUMOURS        73 

the  canal  of  Schlemm,  and  thus  into  the  venous 
circulation.  This  relation  probably  explains  the 
ready  absorptive  powers  of  the  aqueous.  Thus, 
if  pus  finds  its  way  into  the  anterior  chamber 
(hypopyon)  it  is,  as  a  rule,  easily  absorbed.  The 
same  applies  to  moderate  extravasations  of  blood 
in  the  chamber,  and  the  speedy  removal  of  such 
effusions  contrasts  with  the  difficulty  that  is  ex- 
perienced in  the  absorption  of  blood  from  the 
vitreous  chamber. 

Professor  Arthur  Thomson  has  recently  shown 
that  the  inner  aspect  of  the  sclerotic  is  depressed 
or  grooved  at  the  anterior  base  of  the  iris.  When 
the  pupil  is  dilated  the  contracted  base  of  the 
iris  tends  to  fill  this  groove,  thus  rendering  the 
escape  of  the  aqueous  humour  into  the  spaces  of 
Fontana  more  difficult. 

The  vitreous  takes  little  active  share  in  ocular 
maladies.  It  may  be  secondarily  affected  in  in- 
flammation of  adjacent  parts,  may  be  the  seat  of 
haemorrhages,  and  is  often  occupied  by  opaque 
bodies  of  various  kinds.  Foreign  bodies  have  lodged 
in  the  vitreous  for  considerable  periods  without 
causing  any  symptoms.  The  muscse  volitantes  that 
so  often  trouble  the  myopic  are  due  to  little 
opaque  matters  in  the  vitreous,  and  very  often 
have  exactly  the  appearance  that  the  corpuscles 
of  the  vitreous  present  when  seen  under  the 
microscope. 

The  delicate  transparent  membrane  which  en- 
capsules  the  vitreous  humour  is  known  as  the 
hyaloid  membrane.  The  vitreous  is  readily  separ- 
ated from  the  retina  except  behind,  opposite  the 
disc  where  the  artery  to  the  lens  enters  in  the 
foetus  and  passes  forwards  to  supply  the  foetal 
pupillary  membrane.  This  vessel  is  a  branch  of 
the  central  artery  of  the  retina,  and  may  persist 
as  a  fibrous  cord  in  adult  life.  In  some  rare 
cases  it  has  continued  to  transmit  blood,  and  in 
such  instances  its  pulsation  can  be  seen  with  the 
ophthalmoscope. 

Glaucoma    is  a  disease  the  symptoms  of  which 

D* 


74  THE    HEAD    AND    NECK  [Chap. 

are  all  dependent  upon  an  increase  in  the  intra- 
ocular tension  of  the  globe.    The  increased  tension 
is  due  to  an  excess  of  fluid  within  the  eyeball,  and 
this  would  appear  to  result  from  certain  changes, 
seldom  absent  in  the  glaucomatous,  that  interfere 
with  the  normal   escape  of  this  fluid.     Normally 
there  is  a  constant  movement  of  fluid,  through  the 
pupil  from  the  posterior  to  the  anterior  chamber. 
This  fluid  is  derived  mainly  from  the  ciliary  bodies, 
and  in  a  less  degree  from  the  posterior  surface  of 
the  iris.    Atrophy  of  the  epithelium  on  the  ciliary 
body  is  said  to  lead  to  diminished  tension.     From 
the  anterior  chamber  the  fluid  can  escape  into  the 
veins  through  the  gaps  in  the  ligamentum  pecti- 
natum  already  alluded  to  (Fig.  17).     It  is  remark- 
able that  in  nearly  every  case  of  glaucoma  these 
gaps  are  occluded  by  the  complete  obliteration  of 
the  angle  between  the  periphery  of  the  iris  and  the 
cornea,   which  angle  is  normally  occupied  by  the 
ligamentum  pectinatum.     The  importance  of  the 
peripheral  part  of  the  anterior  chamber  in  relation 
to  the  outflow  of  fluid  from  the  eye  is  shown  in 
many  ways.     If  this  part  be  blocked  by  the  iris  in 
perforation  of  the  cornea,  or  by  the  lens  in  some 
dislocations  of  that  body,  increased  tension  of  the 
globe  is  apt  to  follow.  The  relief  given  to  glaucoma 
by  iridectomy  appears  to  depend  upon  the  circum- 
stance  that  the   operation   practically    opens    up 
again  these  channels  of  communication  from  the 
aqueous,    since    the    procedure,    to    be    successful, 
should  involve  an  incision  so  far  back  on  the  sclero- 
tic as  fully  to  pass  through  the  angle  just  alluded 
to.     It  is  needful  also  that  the  iris  should  be  re- 
moved quite  up  to  its  attachment,   and  that  the 
portion  resected  should  be  considerable.      Iridec- 
tomy   also   exposes   a   fresh   capillary   surface    of 
the  iris  to  the  aqueous  humour,  which  thus  finds 
a    fresh    exit.      In    the    young    the    ligamentum 
pectinatum    is   cellular    and    open    in    structure ; 
it    becomes    fibrous    and    contracted    in    the    old. 
Hence  the  aged  are  more  liable  to  glaucoma  (T. 
Henderson). 


. 


IV]  GLAUCOMA  75 

The  symptoms  of  glaucoma  are  all  explained 
by  the  effects  of  the  abnormal  tension.  Thus^  the 
ciliary  nerves  are  compressed  against  the  unyield- 
ing sclerotic,  and  give  rise  to  intense  pain,  while 
the  disturbance  in  their  functions  shows  itself 
in  the  fixed  and  dilated  pupil  and  in  the  anaes- 
thetic cornea.  Perhaps  the  first  parts  to  suffer 
from  compression  are  the  retinal  blood-vessels, 
and  the  effect  upon  them  will  be  most  obvious  at 
the  periphery  of  the  retina,  i.e.  at  the  extreme 
limit  of  the  retinal  circulation.  Hence  follows 
that  gradual  narrowing  of  the  visual  field  which 
is  constant  in  glaucoma,  while  the  pressure  upon 
the  optic  nerve  produces  those  flashes  of  light 
and  other  spectra  which  occur  in  the  disease. 
The  weakest  part  of  the  sclerotic  is  in  the 
disc  at  the  lamina  cribrosa.  This  part  rapidly 
yields  under  the  pressure,  and  so  produces  the 
"glaucomatous  cup."  Pressure  in  the  opposite 
direction  pushes  the  lens  forwards,  and  thus 
narrows  the  anterior  chambers;  while  the  general 
interference  with  the  ocular  circulation  is  shown 
in  the  distended  vessels  that  appear  upon  the 
globe. 

The  eyelids  (Fig.  18). — The  skin  over  the  eye- 
lids is  very  thin  and  delicate,  and  shows  readily 
through  its  substance  any  extravasation  of  blood 
that  may  form  beneath  it.  Its  laxity,  moreover, 
renders  it  very  .well  adapted  for  certain  plastic 
operations  that  are  performed  upon  the  part.  Its 
loose  attachments  cause  it  to  be  readily  influenced 
by  traction,  and  the  shrinking  of  cicatrices  below 
the  lower  lid  is  very  apt  to  draw  that  foM  away 
from  the  globe,  and  so  produce  the  condition  of 
eversion  of  the  lid  known  as  ectropion.  The  con- 
traction of  the  conjunctiva  after  inflammatory  con- 
ditions, or  after  it  has  been  subjected  to  destructive 
agencies,  is  prone,  on  the  other  hand,  to  curl  either 
lid  inwards  towards  the  globe,  and  thus  to  produce 
entropion.  The  lids  present  many  transverse 
folds  ;  one  of  these  on  the  upper  lid,  deeper  and 
more  marked  than  the  rest,   divides  the  lid  into 


76 


THE    HEAD    AND    NECK 


[Chap. 


two  parts,  the  part  below  being  that  which  covers 

the  globe,  the  part 
above  being  that  in 
relation  with  the  soft 
structures  of  the  orbit. 
In  emaciation  the  lid 
becomes  much  sunken 
in  the  line  of  this 
fold.  Incisions  should 
follow  the  direction  of 
the  fold.  The  lids 
are  very  freely  sup- 
plied with  blood,  and 
are  often  the  seat  of 
nsevi  and  other  vas- 
cular growths. 

The  following  layers 
are  found  in  either 
lid  in  order  :  (1)  the 
skin ;  (2)  the  subcu- 
taneous tissue ;  (3)  the 
orbicularis  palpebra- 
rum ;  (4)  the  tarsal 
plate  and  its  continua- 
tion to  the  margin  of 
the  orbit — the  palpe- 
bral membrane ;  (5) 
the  layer  of  Meibomian 
glands  embedded  in 
the  plate;  and  (6)  the 
conjunctiva.  In  the 
upper  lid  the  levator 
palpebrse  is  found 
passing  to  the  tarsal 
plate.  The  subcuta- 
neous tissue  is  very 
lax,  and  hence  the  lids 
swell  greatly  when 
cedematous,  or  when 
inflamed,  and  when 
On  this  account  it 
leeches    to     the     lids, 


'*        9 
Fig.      18. —  Vertical 
through   upper    eyelid. 

Waldeyer.) 


section 

(After 


a,  Skin  ;  b,  orbicularis  ;  V,  its  ciliary- 
part  ;  c,  involuntary  muscle  of 
eyelid  representing  part  of  the 
insertion  of  the  levator  palpe- 
brse  ;  d,  conjunctiva ;  e,  tarsal 
cartilage  ;  /,  Meibomian  gland  ; 
g,  modified  sweat-gland  ;  h,  eye- 
lashes ;  i,  post-tarsal  glands. 

the    seat    of    haemorrhage, 
is     inadvisable     to     apply 


IV]  EYELIDS— CONJUNCTIVA  77 

because  of  the  extensive  "black  eye"  that  may 
follow.  This  tissue  is  peculiar  in  containing  no 
fat.  At  the  edge  of  the  lids  are  found  the  eye- 
lashes, the  orifices  of  the  Meibomian  glands,  and 
of  some  modified  sweat-  and  sebaceous  glands.  The 
secretion  of  these  glands  prevents  adhesion  of  the 
edges  of  the  lid.  This  edge,  like  other  points  of 
junction  of  skin  and  mucous  membrane,  is  apt 
to  be  the  seat  of  irritative  affections.  As  it  is  a 
free  border  also  the  circulation  is  terminal,  and 
stagnation  in  the  blood  current  is  not  difficult  to 
produce.  Sycosis,  an  inflammation  involving  the 
hair-follicles,  and  some  of  the  glands  at  the  edge 
of  the  lid,  is  among  the  most  common  of  ophthal- 
mic affections.  The  common  stye  also  is  a  sup- 
puration in  the  connective  tissue  or  in  one  of 
the  glands  at  the.,  margin.  On  everting  the  lid 
the  Meibomian  glands  can  be  seen  through  the 
conjunctiva  as  lines  of  yellowish  granules.  The 
common  tarsal  cyst  is  a  retention  cyst  developed 
in  one  of  these  glands. 

Two  arteries  supply  either  lid  :  a  palpebral 
branch  of  the  ophthalmic  running  along  the  inner 
part,  and  a  branch  of  the  lachrymal  along  the 
outer  part  of  each  lid.  Four  nerves  supply  the 
upper  eyelid,  the  supraorbital,  the  supratrochlear 
and  infratrochlear,  and  the  lachrymal.  One  nerve 
supplies  the  lower  lid,  the  infraorbital.  Some 
of  the  lymphatics  of  the  eyelids  enter  the  pre- 
auricular glands,  hence  in  cases  of  chancre  of  the 
lid  the  glandular  enlargement  has  nearly  always 
been  noticed  in  front  of  the  parotid  gland.  (Fig. 
44,  p.   197.) 

The  conjunctiva. — The  ocular  part  of  this 
membrane  is  thin,  covered  with  stratified  epithe- 
lium very  loosely  attached,  and  not  very  exten- 
sively supplied  with  blood;  the  palpebral  portion 
is  thicker,  covered  with  columnar  epithelium  more 
closely  adherent,  and  more  vascular.  At  the  edge 
of  the  cornea  the  conjunctiva  becomes  continuous 
with  the  epithelium  covering  that  tunic.  The  loose- 
ness of  the  ocular  conjunctiva  allows  it  to  be  freely 


78  THE    HEAD    AND    NECK  [Chap. 

moved  about,  and  is  of  great  value  in  some  opera- 
tions, as,  for  example,  in  Teale's  operation  for 
symblepharon,  where  a  bridge  of  conjunctiva,  dis- 
sected up  from  the  globe  above  the  cornea,  is  drawn 
down  over  the  cornea  to  cover  a  raw  surface  in  con- 
tact with  the  lower  lid.  This  lax  tissue  favours  the 
development  of  oedema  (chemosis),  which  in  ex- 
treme cases  may  reach  such  a  degree  that  the 
patient  cannot  close  his  eye.  The  vessels  also, 
being  feebly  supported,  are  prone  to  give  way 
under  no  great  provocation.  Thus,  subconjunc- 
tival haemorrhages  may  occur  from  severe  vomit- 
ing, or  durinig  a  paroxysm  of  whooping  cough. 
Blood  also  may  find  its  way  beneath  the  membrane 
in  fractures  of  the  base  of  the  skull.  Haemorrhages 
beneath  the  membrane  are  unlike  other  extravasa- 
tions (bruises),  in  that  they  retain  their  scarlet 
colour.  This  is  due  to  the  fact  that  the  thinness 
of  the  conjunctiva  allows  oxygen  to  reach  the 
blood  and  gives  it  an  arterial  character.  Severe 
inflammation  of  the  conjunctiva  may  lead  to  con- 
siderable cicatricial  changes,  as  is  the  case  in  other 
mucous  membranes,  and  especially,  perhaps,  ( in 
the  urethra.  The  contraction  of  the  conjunctiva 
after  destructive  processes  is  apt  to  lead  to  en- 
tropion. If  both  the  ocular  and  the  corresponding 
part  of  the  palpebral  conjunctiva  have  been  de- 
stroyed, the  two  raw  surfaces  left  will  readily  ad- 
here ;  the  lid  will  become  fused  to  the  globe,  and 
the  condition  called  symblepharon  be  produced. 
This  condition  concerns  the  lower  lid,  and  is  gener- 
ally brought  about  by  lime  or  other  caustics  bein^ 
accidentally  introduced  between  the  under  lid 
and  the  globe. 

In  one  common  form  of  inflammation  of  this 
membrane  a  number  of  little  "  granulations  "  ap- 
pear upon  the  palpebral  conjunctiva.  These  are 
not  real  granulations,  since  no  true  ulceration  of 
the  part  takes  place,  but  they  appear  to  be  made 
up,  some  of  nodules  of  adenoid  tissue,  others^  of 
enlarged  mucous  follicles  and  of  hypertrophied 
papillae,  all  of  which  structures  are  normally  found 


IV]  LACHRYMAL    APPARATUS  79 

in  the  membrane.  The  condition  is  known  as 
"granular  lids," and  is  associated  with  the  form- 
ation of  much  new  tissue  in  the  deeper  parts  of 
the  membrane.  From  the  absorption  of  this  new 
tissue  and  of  these  granulations  a  contracting  cica- 
trix results,  leading  to  much  puckering  of  the 
membrane,  and  often  to  entropion  and  inversion 
of  the  eyelashes.  In  purulent  ophthalmia  the 
cornea  is  in  great  risk  of  destruction,  owing  to 
the  strangulation  of  its  vessels  and  possibly  to  the 
direct  effects  of  the  discharge  upon  the  membrane. 

Lachrymal  apparatus. — The  lachrymal  gland 
is  invested  by  a  special  fascia  which  separates 
it  from  the  general  cavity  of  the  orbit;  and, 
according  to  Tillaux,  this  little  body  can  be 
removed  without  opening  the  greater  space  of  the 
orbit.  The  gland  may  inflame,  and  become  so  en- 
larged as  to  appear  as  a  tumour,  which  may  dis- 
place the  globe  downwards  and  inwards,  and  press 
forwards  the  oculo-palpebral  fold  of  conjunctiva. 
If  an  abscess  forms,  it  most  usually  breaks  through 
the  skin  of  the  upper  lid.  Cyst®  of  the  gland 
(dacryops)  are  due  to  obstruction  and  distension 
of  some  of  its  ducts.  The  normal  secretion  of  the 
gland  keeps  the  exposed  surface  of  the  eye  moist, 
yet  the  gland  may  be  excised  without  giving  rise 
to  any  untoward  effect. 

The  lachrymal  sac  is  situated  at  the  side  of  the 
nose,  near  the  inner  canthus,  and  lies  in  a  groove 
on  the  lachrymal  and  superior  maxillary  bones 
(Fig.  19).  On  its  outer  side,  and  a  little  anteriorly, 
it  receives  the  two  lachrymal  canaliculi.  In  front 
of  the  sac  is  the  tendo  bculi.  If  the  two  lids  be 
forcibly  drawn  outwards  this  tendon  can  be  readily 
felt  and  seen,  and  serves  as  a  guide  to  the  sac.  It 
can  also  be  felt  as  it,is  tightened,  when  the  lids  are 
firmly  closed.  It  crosses  the  sac  at  right  angles> 
and  at  about  the  junction  of  its  upper  third  with 
its  lower  two-thirds.  A  knife  entered  immediately 
below  the  tendon  would  about  open  the  middle  of 
the  sac,  and  it  may  be  noted  that  a  lachrymal 
abscess,   when   about  to   discharge,   always  points 


THE    HEAD    AND    NECK 


[Chap. 


below  the  tendon.  Epiphora,  or  overflow  of  tears, 
is  due  in  the  main  to  two  causes  :  (1)  to  an  obstruc- 
tion in  any  part  of  the  lachrymal  passages  from  the 
puncta  to  the  opening  of  the  nasal  duct  in  the 


Lac*. Gland 
Plica  5emilua4. 

/iASIOAl 

Canaliculus 
I/nt.  Tarsal  Lie. 
Lacn.  5ac 

UL/IasalDuct 


MP.  riEATUS 


Fig.  19. — Diagram  of  the  lachrymal  apparatus. 

The  arrow  points  to  the  first  molar  tooth,  showing  the  direction  of 
the  nasal  duct. 


nose;  (2)  to  any  cause  that  removes  the  lower 
punctum  from  its  contact  with  the  globe,  as  may  be 
the  case  in  ectropion,  in  entropion,  in  swelling  of 
the  lower  lid,  etc.  Facial  palsy  causes  epiphora, 
because,  the  orbicular  muscle  being  relaxed,  the 
punctum  falls  away  from  the   globe,    and,   more- 


IVJ  NASAL    DUCT  81 

over,  the  passage  of  the  tears  is  no  longer  aided 
by  the  suction  action  effected  by  the  muscle  in  the 
process  of  winking.  The  canaliculi  may  readily  be 
slit  up  with  a  proper  knife,  and  a  probe  can 
without  difficulty  be  passed  down  the  nasal  duct 
from  the  lachrymal  sac. 

The  nasal  duct  is  a  little  over  i  an  inch  in 
length,  and  the  probe  that  traverses  it  should  pass 
downwards,  and  a  little  backwards  and  outwards, 
in  the  direction  of  the  first  molar  tooth  (Fig.  19). 
The  nasal  duct  perforates  the  mucous  membrane  of 
the  nose  below  the  inferior  turbinate  process  very 
obliquely,  so  that  its  inner  wall  acts  as  a  valve.  If 
this  is  destroyed  by  ulceration,  as  sometimes  oc- 
curs in  syphilis,  the  lachrymal  sac  may  be  inflated 
by  blowing  the  nose.  The  bony  nasal  duct  has  a 
calibre  which  varies  from  25  to  7'5  mm.  in  dia- 
meter ;  the  thick  mucous  membrane  which  lines 
it  has  a  rich  venous  plexus  in  its  submucous  layer 
which  readily  swells  and  prevents  the  passage  of 
tears  when  the  duct  is  inflamed.  The  normal  duct 
will  take  a  probe  measuring  3*5  mm.  in  diameter ; 
it  must  be  remembered  that  the  lumen  of  the  duct 
is  normally  closed,  and  that  its  lining  membrane 
possesses  several  transverse  folds  which  may  catch 
the  point  of  a  probe.  Inflammatory  conditions 
readily  ascend  from  the  nasal  cavity  to  the  lachry- 
mal sac  through  the  nasal  duct. 

As  affections  of  the  lachrymal  sac  are  often  very 
painful,  it  may  be  noted  that  the  nerve  supply  of 
the  sac  is  derived  from  the  infratrochlear  branch 
of  the  nasal  nerve. 


CHAPTER    V 
THE  EAR 

The  pinna. — The  pinna  may  be  congenitally 
absent,  or  may  be  supplemented  by  supernumerary 
portions  of  the  auricle,  which  may  be  situated 
upon  the  cheek  or  side  of  the  neck.  In  the 
latter  situation  the  so-called  supernumerary 
auricle  consists  of  an  irregular  leaf  of  fibro- 
cartilage  developed  from  the  margins  of  one  of 
the  lower  branchial  clefts.  t  (See  p.  200.)  The 
tag-like  supernumerary  auricles  that  are  found 
on  the  cheek  just  in  front  of  the  pinna  or 
meatus  are  due  to  the  irregular  development  or 
want  of  fusion  of  one  or  more  of  the  six  tubercles 
from  which  the  pinna  itself  is  developed.  The  pinna 
may  present  a  congenital  fistula  dependent  on  a 
defective  closure  of  the  first  branchial  cleft.  The 
position  of  this  cleft  is  represented  in  the  normal 
ear  by  the  Eustachian  tube,  the  tympanum,  and 
the  external  auditory  meatus,  the  pinna  being 
developed  from  the  integument  bordering  the  cleft. 
In  these  congenital  fistulse,  when  well  marked,  the 
pinna  is  cleft  above  or  below  the  meatus.  Some 
of  the  smaller  and  more  superficial  fistulse  are  due 
not  to  a  defective  closure  of  the  branchial  cleft  but 
to  want  of  complete  fusion  between  certain  of 
the  tubercles  from  which  the  pinna  is  primarily 
developed.  Accidental  removal  of  the  pinna  is 
usually  associated  with  but  comparatively  little 
diminution  in  the  acuteness  of  hearing. 

The  skin  covering  the  auricle  is  thin  and  closely 
82 


Chap.  V]      EXTERNAL    AUDITORY    MEATUS  83 

adherent.  The  subcutaneous  tissue  is  scanty,  and 
contains  but  very  little  fat.  In  inflammatory  con- 
ditions of  the  surface,  such  as  erysipelas,  the 
pinna  may  become  extremely  swollen  and  very 
great  pain  be  produced  from  the  tenseness  of  the 
parts.  The  pinna  and  cartilaginous  meatus  are 
very  firmly  attached  to  the  skull,  so  that  the  body, 
if  not  of  great  weight,  may  be  lifted  from  the 
ground  by  the  ears. 

The  external  auditory  meatus  is  about 
lj  inches  long.  It  is  important  to  remember  that 
the  meatus  is  directed  forwards  as  well  as  inwards  ; 
to  reach  and  expose  the  middle  ear  the  surgeon 
takes  the  posterior  wall  of  the  meatus  as  a  guide. 
The  external  meatus,  the  promontory,  the  cochlea, 
and  the  internal  meatus  lie  nearly  in  the  same  line. 
The  canal  has  a  vertical  curve  about  its  middle, 
with  the  convexity  upwards.  To  straighten  the 
canal  for  the  introduction  of  specula  and  other  in- 
struments, the  pinna  should  be  drawn  upwards  and 
a  little  outwards  and  backwards.  The  osseous  part 
forms  a  little  more  than  one-half  of  the  tube,  and  is 
narrower  than  the  cartilaginous  part. 

In  the  infant  at  1  year,  a  third  only  of  the 
meatus  is  formed  of  bone.  The  rest  is  cartilagin- 
ous. In  a  child  5  or  6  years  of  age  the  bony 
and  cartilaginous  portions  of  the  meatus  are  about 
of  the  same  length  (Symington).  The  meatus  is 
relatively  as  long  in  a  child  as  it  is  in  an  adult. 
The  narrowest  portion  of  the  meatus  is  about  its 
middle.  The  outer  orifice  is  elliptical,  with  its 
greatest  diameter  directed  from  above  downwards; 
therefore  specula  should  be  elliptical  in  shape 
rather  than  round.  The  inner  end  of  the  tube,  on 
the  other  hand,  is  slightly  wider  in  the  transverse 
direction.  Owing  to  the  obliquity  of  the  mem- 
brana  tympani,  the  floor  of  the  meatus  is  longer 
than  the  roof.  The  cartilaginous  segment  of  the 
tube  presents  many  sebaceous  glands  that  may  be 
the  seat  of  minute  and  very  painful  abscesses.  It 
also  presents  numerous  ceruminous  glands,  which 
secrete  the  cerumen  of  the  ear,   and  which,  when 


84  THE    HEAD    AND    NECK  [Chap. 

their  secretion  is  excessive,  may  produce  the  plugs 
of  wax  that  often  block  the  meatus  and  cause  deaf- 
ness. In  the  cartilage  of  the  floor  of  the  meatus 
are  certain  fissures,  fissures  of  Santorini.  They  are 
filled  up  with  fibrous  tissue.  They  permit  of  easier 
movement  of  the  cartilaginous  meatus.  It  is 
through  these  gaps  in  the  cartilage  that  a  parotid 
abscess  may  burst  into  the  meatus.  There  are 
neither  hairs  nor  glands  in  the  lining  of  the  bony 
part  of  the  tube. 

The  skin  of  the  meatus,  when  inflamed,  may  pro- 
duce an  extensive  muco-purulent  discharge,  otitis 
externa.  Polypi  are  apt  to  grow  from  the  soft  parts 
of  the  canal,  and  exostoses  from  its  bony  wall. 
Foreign  bodies  are  frequently  lodged  in  the 
meatus,  and  often  involve  great  difficulties  in  their 
extraction.  It  would  appear  that  in  many  cases 
more  damage  is  done  by  the  surgeon  than  by  the 
intruding  substance.  Mason  reports  three  cases 
where  a  piece  of  slate-pencil,  a  cherry-stone,  and  a 
piece  of  cedar-wood  were  lodged  in  the  canal  for 
respectively  forty  years,  sixty  years,  and  thirty 
years. 

The  upper  wall  of  the  meatus  is  in  relation  with 
the  cranial  cavity,  from  which  it  is  only  separated 
by  a  dense  layer  of  bone.  Thus,  abscess  or  bone  dis- 
ease in  this  part  may  possibly  lead  to  meningitis. 
A  case  is  reported  where  an  inflammation  of  the 
cerebral  membrane  followed  upon  the  retention 
of  a  bean  within  the  meatus.  The  anterior  wall 
of  the  canal  is  in  relation  with  the  temporo- 
maxillary  joint  and  with  part  of  the  parotid 
gland.  This  may  serve  in  one  way  to  explain  the 
pain  often  felt  in  moving  the  jaw  when  the 
meatus  is  inflamed,  although,  at  the  same  time,  it 
must  be  remembered  that  movement  of  the  lower 
maxilla  produces  a  movement  in  the  cartilagin- 
ous meatus,  and  that  both  the  canal  and  the  joint 
are  supplied  by  the  same  nerve  (the  auriculo- 
temporal). From  its  relation  to  the  condyle  of 
the  jaw,  it  follows  that  this  wall  of  the^meatus  has 
been  fractured  by  that  condyle  in  falls  upon  the 


V]  THE    EAR  85 

chin.  Tillaux  states  that  abscess  in  the  parotid 
gland  may  spread  into  the  meatus  through  the 
anterior  wall  of  the  passage.  The  posterior  wall 
separates  the  meatus  from  the  mastoid  cells. 
Directly  behind  the  posterior  wall,  at  a  distance 
of  12  or  15  mm.,  is  the  lateral  sinus  (Fig.  22). 
The  inferior  wall  of  the  bony  meatus  is  very 
dense  and  substantial,  and  corresponds  to  the 
vaginal  and  styloid  processes. 

Blood  supply.  —  The  pinna  and  external 
meatus  are  well  supplied  with  blood  by  the  tem- 
poral and  posterior  auricular  arteries,  the  meatus 
receiving  also  a  branch  from  the  internal  maxillary. 
In  spite  of  this  supply,  the  pinna  is  frequently  the 
seat  of  gangrene  from  frost-bite.  This  is  due  to 
the  fact  that  all  the  vessels  are  superficial  and  lie 
close  beneath  the  surface,  that  the  part  is  much 
exposed  to  cold,  and  that  the  pinna  lacks  the  pro- 
tection of  a  covering  of  fat.  The  same  conditions 
predispose  to  gangrene  of  the  nose  from  external 
cold.  Bloody  tumours  (hsematomata)  are  often  met 
with  on  the  pinna,  and  are  common  in  boxers,  foot- 
ball players,  and  lunatics.  They  are  due  to  injury, 
and  consist  of  an  extravasation  between  the 
perichondrium  and  the  cartilage. 

IVerve  supply. — The  pinna  is  supplied  by 
the  auriculotemporal,  great  auricular,  and  small 
occipital  nerves  {see  Fig.  4,  p.  15).  Arnold's  nerve, 
the  auricular  branch  of  the  vagus,  sends  a  twig  to 
the  back  of  the  concha,  near  the  mastoid  process. 
The  meatus  is  supplied  mainly  by  the  auriculo- 
temporal, with,  in  addition,  a  contribution  from 
Arnold's  nerve,  which  goes  to  the  lower  and  back 
part  of  the  canal,  not  far  from  its  commencement. 
Arnold's  nerve  has  been  credited  with  a  good  deal 
in  connexion  with  the  nerve  relations  of  the  ear. 
After  a  heavy  dinner,  when  the  rose-water  comes 
round,  it  is  common  to  see  the  more  experienced 
of  the  diners  touch  the  lower  part  of  the  back  of 
the  ear  with  the  moistened  serviette.  This  is  said 
to  be  very  refreshing,  and  is  supposed  to  be  an 
unconscious  stimulation  of  Arnold's  nerve,  a  nerve 


86  THE    HEAD    AND    NECK  [Chap. 

whose  main  trunk  goes  to  the  stomach.  Hence, 
this  little  branch  has  been  facetiously  termed 
"the  alderman's  nerve." 

Ear   coughing,    ear    sneezing,    ear   yawning.— 

It  is  not  uncommon  to  have  a  troublesome  dry 
cough  associated  with  some  mischief  in  the 
meatus.  Sometimes  the  mere  introduction  of  a 
speculum  will  make  the  patient  cough.  A  case 
is  reported  in  which  a  troublesome  cough  persisted 
for  eighteen  months,  and  at  once  ceased  on  the  re- 
moval of  a  plug  of  wax  from  the  ear.  In  such  cases 
the  irritation  is  conveyed  to  the  respiratory  and 
cough  centres  in  the  floor  of  the  fourth  ventricle  by 
Arnold's  nerve,  a  small  branch  of  the  vagus.  Gas- 
kell  has  shown  that  the  vagus  also  contains  the  dis- 
associated visceral  fibres  of  the  fifth  nerve.  Hence, 
disturbances  may  be  set  up  in  the  vagal  nuclei 
through  branches  of  the  fifth  nerve,  such  as  the 
auriculo-temporal.  The  connexion  of  the  nerves 
of  the  external  auditory  meatus  with  the  vagal 
nuclei  also  explains  the  sneezing  or  vomiting  which 
is  sometimes  caused  by  the  presence  of  foreign 
bodies  in  the  external  meatus.  The  same  nerve- 
connexion  also- explains  the  occurrence  of  repeated 
yawning,  sometimes  set  up  by  ear  ailments.  Irrita- 
tion conveyed  along  the  inferior  dental  or  lingual 
nerves  may  be  referred  along  the  auriculo-tem- 
poral. Hence  the  need  to  examine  the  tongue  and 
lower  teeth  in  cases  of  earache.  Head  has  pointed 
out  that  disease  of  the  ear,  the^  tonsil,  the  tongue, 
or  the  lower  jaw  may  be  associated  with  an  area 
of  tenderness  in  the  skin  along  and  below  the  jaw. 

It  is  a  common  practice  to  introduce  ear-rings 
with  the  idea  of  relieving  obstinate  affections  of  the 
eye.  No  anatomical  basis  can  be  offered  to  explain 
such  treatment.  The  lobule  is  supplied  by  the  great 
auricular  nerve  which  springs  from  the  second 
and  third  cervical  nerves,  while  the  eye  is  supplied 
by  the  ophthalmic  division  of  the  fifth.  The  lower 
sensory  nucleus  of  the  fifth  is  a  direct  continuation 
upwards  of  the  grey  matter  from  which  the  pos- 
terior roots  of  the  cervical  nerves  arise. 


V] 


MEMBEANA    TYMPANI 


87 


Hilton  reports  a  case  of  obscure  pain  in  the  ear 
which  was  found  to  be  due  to  an  enlarged  gland  in 
the  neck,  that  pressed  upon  the  trunk  of  the  great 
auricular  nerve. 

Membrana  tympani.— This  membrane  is  very 
obliquely  placed,  forming  with  the  horizontal  an 
angle  of  45°.   At  birth  it  appears  to  be  more  nearly 


Fig.  20. — Section  through  the  external  meatus,  middle  ear, 
and  Eustachian  tube.     {Tillaux.) 

a,  External  auditory  meatus  ;  b,  attic  of  tympanum  ;  c,  Eustachian 
tube  ;  d,  internal  auditory  meatus  ;  e,  cochlea  ;/,  ossicles  ;  g,  mem- 
brana  tympani :  h,  styloid  process. 

horizontal,  although  it  is  not  really  so.  In  cretins, 
and  in  some  idiots,  it  is  said  to  retain  this  apparent 
inclination.  Owing  to  the  sloping  downwards  of 
the  bony  wall  of  the  meatus  at  its  inner  end,  that 
wall  forms  with  the  lower  edge  of  the  membrane 


88  THE    HEAD    AND    NECK  [Chap. 

a  kind  of  sinus  in  which  small  foreign  bodies 
may  readily  lodge  (Fig.  20).  The  ring  of  bone  to 
which  the  membrane  is  attached  is  deficient  at  its 
upper  and  anterior  part.  The  gap  so  formed  is 
called  the  notch  of  Rivini,  and  is  occupied  by  loose 
connective  tissue,  covered  by  a  continuation  of  the 
lining  of  the  meatus,  and  through  it  pus  may 
escape  from  the  middle  ear  into  the  auditory  canal 
without  perforating  the  membrane.  When  the 
membrane  gives  way  owing  to  a  violent  concussion 
transmitted  through  the  air,  it  often  gives  way 
opposite  the  notch,  its  attachments  here  being  ob- 
viously less  secure  than  elsewhere.  The  membrane 
possesses  but  little  elasticity,  as  shown  by  the  very 
slight  gaping  of  the  part  after  it  has  been  wounded. 
It  is  for  this  reason,  among  others,  that  perfora- 
tions made  in  the  membrane  by  the  surgeon  heal 
so  very  rapidly.  The  membrane  has  been  ruptured 
during  fits  of  sneezing,  coughing,  vomiting,  etc. 
The  same  lesion  has  followed  a  box  on  the  ear,  and 
even  simple  concussions  such  as  that  produced  by 
a  loud  report. 

The  umbo,  or  deepest  point  of  the  depression  in 
the  diaphragm,  is  just  below  the  centre  of  the  en- 
tire membrane,  and  corresponds  to  the  attachment 
of  the  end  of  the  handle  of  the  malleus.  The  rest  of 
the  handle  can  be  seen  through  the  membrane  dur- 
ing life.  The  head  of  the  malleus  is  in  no  con- 
nexion with  the  membrane,  being  situated  in  the 
attic  of  the  tympanum  above  the  level  of  the  mem- 
brane (Fig.  20).  The  segment  of  the  membrane 
above  the  umbo  is  very  freely  supplied  by  vessels 
and  nerves  ;  it  corresponds  to  the  handle  of  the 
malleus,  and  to  the  chain  of  ossicles,  and  is 
opposite  to  the  promontory  and  the  two  fenestras. 
The  chorda  tympani  nerve  also  runs  across  this 
supraumbilical  portion.  The  segment  below  the 
umbo,  on  the  other  hand,  corresponds  to  no  very 
important  parts,  and  is  less  vascular  and  less  sen- 
sitive. Paracentesis  of  the  tympanum  through  the 
membrana  tympani  should  therefore  always  be  per- 
formed in  the  subumbilical  segment.    If  performed 


V]  THE    TYMPANUM  89 

above  the  umbo  the  knife  may  strike  the  incus  and 
loosen  that  bone  from  its  frail  attachments,  or 
the  chorda  tympani  may  be  cut,  which  would 
give  rise  to  a  paralytic  secretion  of  saliva.  The 
malleus  and  stapes  are  too  firmly  attached  to  be 
readily  detached. 

The  membrane  is  supplied  by  the  stylo-mastoid 
artery  and  the  tympanic  branch  of  the  internal 

Antrum 

,Ext.  Semicirc.  Canal 
,VH»MeR*E 

Aditus 
Fenestra  Ovaus 
Tec  me/s     TyAtPANi 
Processus  Cocm. 


3«-52^ 


,  MOnroRy   ^>^  ( 

PYRAMID  \^\    \, 

Fenestra  Rotunda    i  \    \ 


vIastoid  Cells 
Mastoid  Process 


Fig.  21. — Inner  wall  of  tympanum  and  antrum. 

The  position  of  the  external  semicircular  canal  and  course  of  the 
facial  nerve  (vii.)  are  shown. 

maxillary,  and  obtains  its  nerve  supply  from  the 
auriculo-temporal  and  vagus. 

The  tympanum.— The  width  of  the  tympanic 
cavity,  as  measured  from  its  inner  to  its  outer  wall, 
varies  from  2  to  4  mm.,  ^Wth  to  Jth  of  an  inch.  The 
narrowest  part  is  that  "between  the  umbo  of  the 
membrana  and  the  promontory.  A  fine  rod  thrust 
through  the  centre  of  the  membrana  tympani  would 
hit  the  promontory  of  the  inner  wall  of  the  cavity. 
Above  the  promontory  is  the  fenestra  ovalis,  and 
below  and  behind  it  the  fenestra  rotunda  (Fig.  21). 


90  THE    HEAD    AND    NECK  [Chap. 

Skirting  the  upper  and  posterior  margin  of  the 
inner  wall  of  the  tympanum  is  the  aqueduct  of 
Fallopius,  containing  the  facial  nerve.  The  wall  of 
the  aqueduct  is  so  thin  that  inflammatory  mischief 
can  readily  extend  from  the  middle  ear  to  the  facial 
nerve.  The  upper  wall  is  very  thin,  and  but  little 
bone  separates  it  from  the  cranial  cavity.  The 
suture  between  the  squamous  and  petrous  bones  is 
found  in  this  wall,  and  by  means  of  the  sutural 


Fig.   22. — Showing    the  rposition   and  relationships  of  the 
various  parts  of  the  middle  ear.      (See  also  Fig.  3,  p.  12.) 

membrane  that  separates  the  bones  in  the  young, 
inflammatory  changes  may  readily  spread  from  the 
tympanum  to  the  meninges.  The  petro-squamous 
suture  unites  at  the  end  of  the  first  year  and  usually 
contains  the  petro-squamous  vein,  a  remnant  of 
the  primitive  jugular.  The  floor  is  very  narrow.  Its 
lowest  part  is  below  the  level  of  both  the  mem- 
brana  tympani  and  the  orifice  of  the  Eustachian 
tube,  and  hence  pus  may  readily  collect  in  this 
locality  (Fig.  21).     It  is  separated  by  a  thin  piece 


V]  MASTOID    ANTRUM  91 

of  bone  from  the  internal  jugular  vein  behind,  and 
from  the  internal  carotid  artery  in  front.  Fatal 
haemorrhage  from  the  latter  vessel  has  occurred  in 
connexion  with  destructive  changes  in  this  part  of 
the  ear.  The  posterior  wall  in  its  upper  part  pre- 
sents the  opening  or  aditus  of  the  antrum  of  the 
mastoid.  The  antrum  opens  into  the  attic — that 
part  of  the  tympanic  cavity  which  is  situated  above 
the  level  of  the  membrana  tympani  (Fig.  22). 

The  antrum  of  the  mastoid  (Figs.  20, 
22)  lies  above  and  behind  the  external  auditory 
meatus.  Implication  of  this  space  and  of  the  mas- 
toidal cells,  which  open  into  it  and  surround  it, 
forms  one  of  the  most  serious  complications  of 
middle-ear  disease.  It  is  large  enough  to  contain  a 
small  bean,  and  is  present  at  birth  (Fig.  23),  being 
developed  with  the  cavity  of  the  tympanum.  It  is 
closely  surrounded  by  important  structures.  Its 
roof,  formed  by  the  tegmen  tympani,  a  plate  of 
bone  only  2  mm.  thick,  separates  it  from  the  third 
temporal  convolution.  Small  veins  perforate  the 
roof  to  join  the  petro-squamous  vein,  in  the  rem- 
nant of  the  suture  of  the  same  name.  In  the  infant 
the  communication  is  even  more  free,  for  this 
suture  does  not  close  until  the  end  of  the  first  year. 
The  facial  nerve  passes  downwards  on  its  inner 
wall,  where  the  antrum  opens  into  the  attic,  and 
behind  the  facial  nerve,  also  on  the  inner  wall,  is 
the  external  semicircular  canal  (Fig.  21).  Facial 
paralysis  or  giddiness  may  follow  operations  on  the 
antrum  if  the  inner  wall  is  injured.  The  superior 
and  posterior  borders  of  the  meatus  indicate  the 
position  of  the  facial  nerve  (Fig.  22)  ;  on  the  inner 
wall  of  the  antrum,  the  nerve  is  situated  14  to  22 
mm.  deep  to  the  suprameatal  triangle  (Joyce). 
The  antrum  is  separated  from  the  lateral  sinus 
and  cerebellum  behind  by  a  plate  of  bone  which 
varies  in  thickness  from  3  mm.  to  6  mm.  The 
temporo-sphenoidal  lobe,  the  lateral  sinus,  and 
the  cerebellum  are  the  common  seats  of  secondary 
infection  in  cases  of  middle-ear  disease.  At  the 
mouth   of   the    antrum    and   in    the    attic    of    the 


92 


THE    HEAD    AND    NECK 


[Chap. 


tympanum  are  situated  the  incus,  the  head  of  the 
malleus,  and  their  ligaments,  structures  which 
may  be  diseased  and  require  removal. 

At  birth  the  outer  wall  of  the  antrum  is  formed 
by  the  postmeatal  process  of  the  squamosal,  a 
plate  of  bone  2  mm.  thick  (Fig.  23).  In  the  child  the 
antrum  is  comparatively  superficial,  and  pus  may 
easily  escape  or  be  evacuated.  The  suture  between 
the  postmeatal  part  of  the  squamosal  and  the 
petro-mastoid  disappears  in  the  second  year  of  life, 


Squamosal 
Aaitrum 
Attic 


POST.I/MF.  FONTANELLE 


A/IT.   IMP.    fO/iTAAiELLE 


Squano  /Iasto 
Suture 

/Iastoid^  "     'TyM PA/SIC  RlrtQ 

Drum 
Stylomastoid  Foramen 

Fig.  23. — Temporal  bone  at  birth. 

The  position  of  the  antrum  and  attic  is  indicated.    The  squamo- 
mastoid  suture  is  open  and  the  mastoid  process  undeveloped. 

and  so  shuts  off  a  possible  route  that  pus  may  take 
to  reach  the  surface  (Fig.  23).  The  outer  wall  of 
the  antrum  steadily  increases  in  thickness  until 
adult  life,  when  the  depth  of  the  cavity  from  the 
surface  of  the  bone  is  found  to  vary  in  different  in- 
dividuals from  12  to  22  mm.,  about  16  mm.  being 
its  average  depth.  A  shallow  triangle  (see  Fig.  22) 
above  and  behind  the  meatus  lies  directly  over  the 
antrum  and  serves  as  a  guide  to  its  position.  It 
may  also  be  reached  by  following  the  junction  of 
the  posterior  wall  and  roof  of  the  external  auditory 


V]  MASTOID    CELLS  93 

meatus.  The  drill  is  entered  5  mm.  behind  the 
meatus  and  on  a  level  with  its  upper  margin.  Its 
roof  lies  5  mm.  above  the  level  of  the  meatus.  The 
posterior  auricular  artery  passes  upwards  behind 
the  meatus,  beneath  the  concha  of  the  auricle,  and 
lies  within  the  field  of  any  operation  on  the  middle 
ear. 

The  mastoid  cells  develop  with  the  growth  of 
the  mastoid  process,  which  appears  as  a  definitely 
marked  structure  in  the  second  year.  Besides  the 
antrum  there  are  also  some  cells  present  in  the 
outer  wall  at  birth  (Young).  During  infancy 
there  are  two  types  of  mastoid  :  one  in  which 
the  bone  is  dense — a  form  which  persists  in 
1  per  cent,  of  adults;  and  one  in  which  the 
mastoid  is  diploetic — a  form  which  is  retained 
in  20  per  cent,  of  adults  (A.  Cheatle).  Three 
varieties  of  the  mastoid  process  are  recognized 
in  adults,  each  of  which  is  about  equally  com- 
mon :  (1)  those  in  which  the  cells  are  large  and 
communicate  with  each  other  and  with  the  antrum, 
(2)  those  in  which  the  central  cells  are  large  and 
communicate  with  the  antrum,  while  the  peripheral 
are  small  and  closed,  (3)  those  in  which  all  the 
spaces  are  small  and  closed.  The  cells  surround 
the  antrum,  and  may  pass  backwards  to  the  masto- 
occipital  suture,  forwards  to  the  suprameatal 
region,  upwards  to  the  masto-parietal  suture,  and 
downwards  to  the  apex  of  the  mastoid.  Inflamma- 
tory conditions  may  lead  to  a  thickening  of  the 
walls  of  the  mastoidal  cells,  and  the  bone  may  be- 
come so  dense  as  almost  to  resist  the  chisel.  Veins 
drain  into  the  periosteum  of  the  mastoid  from  the 
more  superficial  cells,  and  by  these  inflammation 
may  reach  the  surface  and  give  rise  to  oedema  and 
swelling  behind  the  ear. 

In  cases  where  the  outer  surface  of  the  mastoid 
has  been  spontaneously  perforated,  a  tumour, 
containing  air,  has  appeared  on  the  skull,  and 
it  has  been  ^  observed  that  the  tumour  may 
be  increased  in  size  by  forcing  air  into  the  ear 
through  the  Eustachian  tube.     Such  tumours  are 


94  THE    HEAD    AND    NECK  [Chap. 

known  as  pneumatoceles,  and  the  process  that 
leads  originally  to  the  perforation  of  the  bone  is 
of  obscure  nature.  In  some  cases  it  seems  to  have 
been  simply  atrophic,  and  in  other  instances  to 
have  been  due  to  "  caries  sicca." 

On  the  anterior  wall  of  the  tympanum  is  the 
opening  of  the  Eustachian  tube  (Figs.  20  and 21). 
This  tube  is  If  inches  long,  and  by  opening  into  the 
pharynx  serves  to  keep  a  proper  supply  of  air  in 
the  tympanum,  and  so  equalize  the  pressure  upon 
the  two  sides  of  the  membrane.  The  floor  of  the 
tympanum  is  below  the  level  of  the  outer  opening  of 
the  Eustachian  tube.  The  line  of  direction  of  the 
tube  lies  almost  exactly  midway  between  the  trans- 
verse and  antero-posterior  axes  of  the  base  of  the 
skull.  In  the  adult  it  inclines  downwards,  so  as  to 
form  an  angle  of  40°  with  the  horizontal.  In  the 
child  this  angle  is  only  10°  (Symington).  In  adults 
jths  of  the  tube  is  cartilaginous  and  ith  bony 
(Symington).  On  the  outer  side  of  the  tube  lie  the 
tensor  palati,  the  third  division  of  the  fifth  nerve, 
and  the  middle  meningeal  artery.  On  the  inner 
side  are  the  retropharyngeal  tissue  and  (quite  pos- 
teriorly) the  internal  carotid  artery.  The  pharyn- 
geal orifice  of  the  tube  is  usually  shut.  During 
swallowing,  however,  it  is  opened  by  the  action 
mainly  of  the  tensor  palati  muscle.  If  the  nose  and 
mouth  be  closed  and  the  cheeks  blown  out,  a  sense 
of  pressure  is  produced  in  both  ears.  The  hearing, 
at  the  same  time,  is  dulled,  and  the  change  is  due 
to  the  bulging  out  of  the  membrana  tympani  by  the 
air  thus  forced  into  the  tympanum.  This  method 
of  inflating  the  middle  ear  is  known  as  Valsalva's 
method. 

In  Politzer's  method  of  passing  air  into  the 
Eustachian  tube,  the  patient's  mouth  is  closed, 
while  into  one  nostril  the  nozzle  of  a  caoutchouc 
bag  filled  with  air  is  introduced,  and  the  nostrils 
are  then  held  firmly  closed.  The  patient  is  asked  to 
swallow  a  mouthful  of  water,  while  at  the  same 
moment  the  bag  is  forcibly  emptied,  and  the  air, 
having  no  other  means  for  escape,  is  thus  driven 


V]  EUSTACHIAN    TUBE  95 

into  the  open  Eustachian  tube.  The  surgeon  listens 
for  the  little  noise  caused  by  the  entrance  of  the 
air  by  means  of  a  tube  that  passes  between  the 
patient's  meatus  and  his  own.  Prolonged  closure 
of  the  Eustachian  tube  leads  to  deafness,  and  thus 
impairment  of  hearing  may  follow  upon  great 
thickening  of  the  mucous  membrane  of  the  tube  due 
to  the  extension  of  inflammatory  mischief  from  the 
pharynx.  In  the  deafness  associated  with  enlarged 
tonsils  and  postnasal  growths,  the  hypertrophic 
change  extends  to  the  mucous  lining  of  the  tube, 
and  in  the  cases  of  many  pharyngeal  growths  and 
nasal  polypi,  the  orifice  of  the  tube  is  mechanically 
obstructed.  The  near  relation  of  the  pharyngeal 
end  of  the  tube  to  the  posterior  nares  serves  to 
explain  a  case  where  suppuration  in  the  mastoid 
cells  followed  upon  plugging  of  the  nares  for 
epistaxis.  Infection  may  be  carried  up  to  the 
middle  ear  by  means  of  the  ciliated  lining  of  the 
Eustachian  tube  ;  C.  J.  Bond  found  that  indigo 
particles,  which  had  been  blown  within  the  naso- 
pharynx, in  a  case  of  perforation  of  the  drum,  ap- 
peared afterwards  in  a  discharge  from  the  external 
meatus. 

The  upper  edge  of  the  pharyngeal  orifice  of  the 
tube  is  about  \  an  inch  below  the  basilar  process, 
i  an  inch  in  front  of  the  posterior  wall  of  the 
pharynx,  \  an  inch  behind  the  posterior  end  of 
the  inferior  turbinate  bone,  and  h  an  inch  above 
the  soft  palate  (Tillaux).  In  the  foetus  the  orifice 
is  below  the  hard  palate;  at  birth,  on  the  same, 
level.  The  form  of  the  opening  is  that  of  a 
triangle.  The  opening  of  the  tube  is  effected  by 
the  tensor  palati,  levator  palati,  and  salpingo- 
pharyngeus. 

Just  behind  the  elevation  formed  at  the  orifice 
of  the  Eustachian  tube  there  is  a  depression  in  the 
wall  of  the  pharynx,  the  lateral  recess  or  fossa 
of  Rosenmiiller  (Fig.  25,  p.  106).  It  may  be  mis- 
taken for  the  orifice  of  the  tube,  and  may  readily 
engage  the  point  of  a  Eustachian  catheter.  In 
cases  in   which  the   pharyngeal  tonsil   (Luschka's 


96  THE    HEAD    AND    NECK  [Chap. 

tonsil)  is  enlarged,  this  fossa  on  either  side  may 
be  greatly  deepened  and  made  to  form  a  narrow 
diverticulum.  (See  p.  159.)  To  pass  the  Eus- 
tachian catheter,  the  instrument  is  carried  along 
the  floor  of  the  nares  with  its  concavity  down- 
wards, "  until  its  point  can  be  felt  to  drop  over 
the  posterior  edge  of  the  hard  palate  into  the 
pharynx.  The  instrument  should  now  be  with- 
drawn until  its  point  can  be  felt  to  rise  again  on 
the  posterior  edge  of  the  hard  palate ;  having 
arrived  at  this  point,  the  catheter  should  be 
pushed  onwards  about  1  inch,  and  during  its 
passage  its  point  should  be  rotated  outwards 
through  a  quarter  of  a  circle. ?;  This  manoeuvre 
should  engage  it  on  the  orifice  of  the  tube. 

Blood  supply.— The  tympanum  is  supplied  by 
the  following  arteries  :  The  tympanic  of  the  in- 
ternal maxillary  and  internal  carotid,  the  petro- 
sal of  the  middle  meningeal,  and  the  stylo-mastoid 
of  the  posterior  auricular.  The  fact  that  some  of 
the  tympanic  veins  end  in  the  superior  petrosal 
and  lateral  sinuses  gives  another  explanation  of 
the  frequent  occurrence  of  thromboses  of  those 
channels  in  inflammatory  affections  of  the  middle 
ear.  The  petro-squamous  vein,  which  crosses  the 
roof  of  the  middle  ear,  also  receives  branches 
from  the  antrum  and  attic  and  joins  the  lateral 
sinus  behind  and  the  meningeal  veins  in  front 
(Cheatle). 

The  lymphatics  of  the  middle  ear  follow  two 
routes.  The  majority  pass  along  the  wall  of  the 
Eustachian  tube  and  end  in  the  retropharyngeal 
lymphatic  gland.  Others  reach  the  postauricular 
group  of  glands,  situated  over  the  mastoid  process, 
by  passing  out  beneath  the  lining  membrane  of 
the  meatus  and  by  other  efferent  channels  which 
accompany  the  veins  escaping  by  the  superficial 
openings  that  are  seen  on  the  mastoid  part  of 
the  temporal. 

The  chorda  tympani  nerve,  from  its  exposed 
position  in  the  tympanum,  is  very  likely  to  be 
damaged    in    suppurative    disease   of    the    middle 


VJ  OSSEOUS    LABYRINTH  97 

ear ;  and  it  has  been  shown  that,  when  this  nerve 
is  involved,  there  may  be  a  disturbance  in  the 
sense  of  taste,  which  is  easily  understood  when 
one  remembers  that  some  of  the  nerves  of  taste 
reach  the  tongue  by  this  route. 

The  osseous  labyrinth  is  formed  independ- 
ently of  the  other  bony  parts  of  the  ear.  Portions 
of  this  labyrinth  have  necrosed  and  have  been 
expelled  in  recognizable  fragments.  In  a  case 
recorded  by  Dr.  Barr  the  whole  of  the  osseous 
labyrinth  (the  cochlea,  vestibule,  and  semicircular 
canals)  was  removed  entire  as  a  necrosed  frag- 
ment from  the  auditory  meatus.  Suppuration  of 
the  middle  ear  may  spread  to  the  inner  ear,  either 
through  the  fenestra  ovalis,  in  which  the  foot- 
plate of  the  stapes  is  fixed  by  the  strong  annular 
membrane,  or  by  the  fenestra  rotunda,  which  is 
closed  by  the  membrana  secundaria.  From  the 
inner  ear  the  suppurative  process  may  extend  in- 
wards along  the  auditory  nerve  and  meatus,  thus 
reaching  the  large  subarachnoid  spaces  at  the  base 
of  the  brain.  Middle-ear  disease  may  lead  to  the 
formation  of  a  fistulous  opening  in  the  external 
semicircular  canal.  In  such  cases  movements  of 
the  head  may  give  rise  to  nystagmus,  for  reflex 
movements  of  the  eyes  are  influenced  by  stimuli 
which  arise  in  the  maculse  of  the  semicircular 
canals  (Sydney  Scott). 


CHAPTER    VI 
THE   NOSE    AND   NASAL    CAVITIES 

The  Nose 

The  skin  over  the  root,  and  the  greater  part 
of  the  dorsum,  of  the  nose  is  thin  and  lax. 
Over  the  alse,  however,  it  is  thick,  very  adherent 
to  the  deeper  parts,  and  plentifully  supplied 
with  sebaceous  and  sweat  glands.  Inflamma- 
tion of  the  integuments  over  the  cartilaginous 
portion  of  the  nose  is  apt  to  be  very  painful, 
and  to  be  associated  with  much  vascular  engorge- 
ment. The  pain  depends  upon  the  tenseness  of  the 
part,  which  prevents  it  from  swelling  without  pro- 
ducing much  pressure  upon  the  nerves,  while  the 
engorgement  depends  upon  the  free  blood  supply 
of  the  region,  and  the  fact  that  the  edge  of  the 
nostril  being  a  free  border,  the  circulation  there 
is  terminal,  and  apt  therefore  to  favour  con- 
gestion. 

The  great  number  of  sebaceous  glands  about 
the  lower  part  of  the  nose  renders  it  a  favourite 
spot  for  acne.  It  is  here  that  the  form  of  acne 
termed  acne  hypertrophica  is  met  with — a  con- 
dition that  produces  the  appearance  known  as 
44  grog  blossoms."  The  nose,^  too,  is  frequently 
attacked  by  lupus,  and  it  is  over  the  dorsum 
of  the  nose  that  lupus  erythematosus  is  most 
commonly  met  with.  ^  Rodent  ulcer  also  is  apt 
to  appear  in  this  region,  especially  in  the  fold 
between  the  ala  of  the  nose  and  the  cheek, 
98 


Chap.  VI]  THE    NOSE  99 

The  integument  of  the  nose  is  very  well  sup- 
plied with  blood,  and  for  this  reason  the  part  is 
well  suited  for  the  many  plastic  operations  that 
are  performed  upon  it.  Wounds  in  this  region 
heal  kindly,  and  even  the  extensive  wound  made 
along  the  line  between  the  nose  and  the  cheek  in 
removal  of  the  upper  jaw  leaves  very  little  de- 
formity. In  many  reported  cases  portions  of  the 
nose  have  been  entirely  severed,  and  have  united 
to  the  face  on  being  immediately   re-applied.  t 

The  skin  over  the  root  of  the  nose  is  supplied 
by  the  nasal  branch  of  the  first  division  of  the 
fifth;  as  is  also  the  skin  over  the  alae  and  in 
the  region  of  the  nostril  (Fig.  4,#  p.  15). ^  The 
greater  part  of  the  side  of  the  nose  is  supplied  by 
the  second  division  of  the  fifth,  and  is  the  seat  of 
pain  in  neuralgia  of  that  trunk.  The  fact  that 
the  nasal  nerve  is  a  branch  of  the  ophthalmic 
trunk,  and  has  intimate  connexions  with  the  eye, 
serves  to  explain  the  lachrymation  that  often 
follows  painful  affections  about  the  nostril,  as, 
for  example,  when  the  edge  of  the  nostril  is 
pinched. 

The  cartilaginous  part  of  the  nose  is  often 
destroyed  by  lupus,  by  syphilitic  ulceration,  and 
other  destructive  affections.  The  parts  so  lost 
have  been  replaced  by  the  various  methods  in- 
cluded under  the  head  of  rhinoplasty.  It  is  well 
to  bear  in  mind  the  limits  of  the  cartilaginous 
segment  of  the  nose,  and  to  remember  that  in  in- 
troducing a  dilating  speculum  the  instrument 
should  not  be  passed  beyond  those  limits.  In  the 
subjects  of  inherited  syphilis  the  bridge  of  the 
nose  is  often  found  to  be  greatly  depressed.  This 
depends  upon  no  actual  loss  of  parts,  but  rather 
upon  imperfect  development  f  rom  ^  local  mal- 
nutrition, that  malnutrition  following  upon  a 
severe  catarrh  of  the  mucous  membrane.  The  de- 
formity only  occurs,  therefore,  in  those  who  have 
had  "  snuffles  "  in  infancy. 

The  nasal  bones ,  are,  often,  .broken  Jby  direqt 
violence.     The  fracta^e"  itf  most  common  through 


100  THE    HEAD    AND    NECK  [Chap. 

the  lower  third  of  the  bones,  where  they  are  thin- 
nest and  least  supported.  It  is  rarest  in  the 
upper  third,  where  the  bones  are  thick  and  firmly 
held5>  and  where,  indeed,  considerable  force  is 
required  to  produce  a  fracture.  Since  no  muscles 
act  upon  the  ossa  nasi,  any  displacement  that 
occurs  is  due  solely  to  the  direction  of  the  force. 
Union  takes  place  after  these  fractures  with 
greater  rapidity  than  perhaps  obtains  after  frac- 
ture of  any  other  bone  in  the  body.  In  one  case 
noted  by  i  Hamilton,  "  the  fragments  were  quite 
firmly  united  on  the  seventh  day."  If  the  mucous 
membrane  of  the  nose  be  torn,  these  fractures  are 
apt  to  be  associated  with  emphysema  of  the  sub- 
cutaneous tissue,  which  is  greatly  increased  on 
blowing  the  nose.  The  air  in  such  cases  is  de- 
rived, of  course,  from  the  nasal  fossse.  In  frac- 
tures of  the  upper  third  of  the  ossa  nasi  the 
cribriform  plate  may  be  broken,  but  it  is  ques- 
tionable whether  this  complication  can  occur 
when  the  fracture  is  limited  to  the  lower  third 
of  the  bones.  The  root  of  the  nose  is  a  favourite 
place  for  meningoceles  and  encephaloceles,  the 
protrusion  escaping  through  the  suture  between 
the  nasal  and  frontal  bones.  Such  protrusions, 
when  occurring  in  this  place,  are  often  covered 
with  a  thin  and  vascular  integument,  and  have 
been  mistaken  for  nsevoid  growths. 

The  Nasal  Cavities 
The  anterior  nares  have  somewhat  the 
shape  of  the  heart  on  a  playing-card,  and  the 
aperture  as  a  whole  measures  about  lj  inches 
vertically,  and  a  little  less  than  \\  inches  trans- 
versely, at  its  widest  part.  The  plane  of  the 
nostril  is  a  little  below  that  of  the  floor  of 
the  nares.  To  examine  the  nasal  cavities,  there- 
fore, the  head  should  be  thrown  back  and  the 
nose  drawn  upwards.  The  anterior  nares  can  be 
well  explored  by  the  finger  introduced  into  the 
nostril,  and  the  r>asaj  apertures. are  just  so  wide 
on'. each  side  of  the  septum  "an  id  allow  the  finger 


.VI]  THE    NARES  101 

to  be  passed  far  enough  back  to  reach  another 
finger  introduced  into  the  posterior  nares  through 
the  mouth.  An  effectual  way  of  removing  soft 
polypi  in  the  adult  is  by  tearing  them  away  by 
two  fingers  so  introduced.  The  operation  is  a 
little  rough.  By  the  most  gentle  introduction  of 
the  finger  into  the  nostril  it  is  often  possible  to 
feel  the  end  of  the  inferior  turbinated  bone.  The 
anterior  nares,  and  front  of  the  nasal  cavities, 
can  be  well  explored  by  Rouge's  operation.  In 
this  procedure  the  upper  lip  is  everted,  and  a 
transverse  cut  made  through  the  mucous  mem- 
brane into  the  soft  parts  that  connect  the  upper 
lip  with  the  upper  jaw.  The  incision  extends  be- 
tween the  second  bicuspid  teeth  of  either  side. 
The  soft  parts  connecting  the  upper  lip  and  nose 
to  the  bone  are  divided  without  damaging  the 
skin,  and  the  flap  is  dissected  up  until  the  nares 
are  sufficiently  exposed. 

Posterior  nares.— If  a  little  mirror,  some- 
what similar  to  that  used  in  laryngoscopy, 
be  cautiously  introduced  behind  the  soft  palate 
through  the  mouth,  and  illumined  from  the  mouth, 
the  following  parts  may,  in  favourable  circum- 
stances, be  seen,  viz.  the  posterior  nares,  the 
septum,  the  middle  turbinated  bone,  part  of  the 
superior  and  inferior  turbinated  bones,  and  part 
of  the  inferior  meatus.  The  middle  meatus  is  well 
seen,  and  also  the  Eustachian  tube,  and  the 
mucous  membrane  of  the  upper  part  of  the 
pharynx. 

This  mode  of  examination  is  very  difficult  to 
carry  out,  and  is  known  as  posterior  rhinoscopy. 
The  parts  just  named  can  all  be  felt  by  the  finger 
introduced  behind  the  soft  palate  through  the 
mouth.  The  posterior  nares  are  often  plugged  to 
arrest  severe  bleeding  from  the  nose,  and  in  order 
to  cut  a  proper-sized  plug  it  is  desirable  to  bear 
in  mind  the  dimensions  of  the  apertures.  Each 
aperture  is  of  regular  shape,  and  measures  about 
i  an  inch  transversely  by  l\  inches  in  the  vertical 
direction  in  a  well-developed  adult  skull. 


102 


THE    HEAD    AND    NECK 


[Chap. 


As  regards  the  nasal  cavities  generally,  it  is 
well  to  note  that  the  floor  is  wider  at  the  centre 
than  at  either  end,  that  the  vertical  diameter  is 
greater  than  the  transverse,  and  is  also  greatest 
about  the  centre  of  the  fossae.  Forceps  introduced 
into  the  nose,  therefore,  are  most  conveniently 
opened  if  opened  vertically.  The  width  of  the 
fossae  increases  somewhat  from  above  downwards ; 
thus  the  superior  turbinated  bone  is  only  2  mm. 
from    the    septum,    while    a    space    of    from   4    to 


Fig.  24. — Transverse  vertical  section  of  the  nasal  cavities 
and  accessory  sinuses. 

5  mm.  intervenes  between  the  inferior  turbinated 
bone  and  the  septum.  The  nasal  cavity  is  so  very 
narrow  above  the  middle  turbinated  bone  that 
that  bone  really  forms  the  surgical  roof  of  the 
nasal  fossae. 

The  shape  and  proportions  of  the  nasal 
cavity  in  the  child  are  peculiar.  In  the  adult 
the  inferior  meatus  is  large  (Fig.  24),  and  con- 
stitutes the  chief  respiratory  passage  ;  in  the  young 
child  the  inferior  meatus  is  relatively  very  small, 
the  middle  meatus  affording  the  main  space  for  the 


VI]  NASAL    CAVITIES  103 

respiratory  tide  (Lack).  The  nasal  cavities  grow 
rapidly  from  the  sixth  to  the  eighteenth  year ; 
during  this  period  the  permanent  dentition  is  be- 
ing formed,  necessarily  causing  an  increase  in  the 
size  of  the  palate  and  of  the  floor  of  the  nose ;  at 
the  same  time  the  development  of  the  antrum  of  the 
maxilla  leads  to  an  increase  in  the  vertical  height 
of  the  nose,  this  increase  affecting  the  lower  or 
maxillary  much  more  than  the  ethmoidal  or  olfac- 
tory part  of  the  cavity.  Growth  of  the  nasal 
cavities  and  of  the  face  may  be  arrested  or  viti- 
ated by  any  obstruction  to  the  free  passage  of  the 
breath  through  the  nose ;  the  most  common  cause 
of  obstruction  is  the  formation  of  adenoids  in  the 
naso-pharynx. 

By  referring  to  the  relations  of  the  nasal  fossse 
(Figs.  24,  25)  it  will  be  understood  that  inflam- 
mation of  the  lining  membrane  (coryza)  may  ex- 
tend to  the  pharynx  via  the  posterior  nares ;  may 
extend  up  the  Eustachian  tube  and  cause  some 
deafness;  may  reach  the  lachrymal  sac  and  con- 
junctiva through  the  nasal  duct;  and  may  extend 
to  the  frontal  sinuses  and  the  antrum,  producing 
frontal  headache  and  cheekache.  These  relation- 
ships are  often  demonstrated  in  a  severe  "  cold 
in  the  head."  From  the  nearness  of  the  nasal 
fossse  to  the  cranial  cavity  it  happens  that  menin- 
gitis has  followed  upon  purulent  inflammations  of 
the  nose.  Foreign  bodies  of  various  kinds  are 
often  lodged  in  the  nose,  and  may  remain  there 
for  some  years.  Thus,  Tillaux  reports  the  case 
of  an  old  woman  aged  64,  from  whose  nose  he 
removed  a  cherry-stone  that  had  been  there  for 
twenty  years. 

In  washing  out  the  nasal  cavities  with  the 
"  nasal  douche  "  the  fluid  is  introduced  by  means 
of  a  siphon.  The  nozzle  of  the  siphon  tube  is 
introduced  into  one  nostril,  the  mouth  is  kept 
open,  and  the  fluid  runs  through  that  nostril, 
passes  over  the  soft  palate,  and  escapes  from  the 
other  nostril.  The  latter  cavity  is  therefore 
washed  out  from  behind  forwards.     The  course  of 


104  THE    HEAD    AND    NECK  LChap. 

the  fluid  depends  upon  the  fact  that  when  the 
mouth  is  kept  open  there  is  such  a  disposition  to 
breathe  through  it  alone  that  the  soft  palate  is 
drawn  up  and  the  nares  cut  off  from  the  pharynx. 
The  root  of  each  nasal  fossa  is  very  narrow, 
being  only  about  J  of  an  inch  in  width  (Fig.  24). 
It  is  mainly  formed  by  the  thin  cribriform  plate, 
but  its  width  is  such  that  the  danger  of  the 
roof  being  penetrated  by  so  large  a  substance  as  a 
pair  of  polyp  forceps  has  been  greatly  exaggerated. 
The  cranial  cavity  has,  however,  been  opened  up 
through  the  roof  of  the  nose  by  penetrating  bodies 
introduced  both  by  accident  and  with  homicidal 
intent.  Meningitis  has  followed  inflammation  of 
the  nasal  fossse,  the  inflammation  extending 
through  the  cribriform  plate.  Through  the  peri- 
neural and  perivascular  sheaths  the  lymphatic 
system  of  the  nose  is  in  continuity  with  that  of 
the  meninges,  and  by  these  channels  infections 
may  spread  from  the  roof  of  the  nose  to  the  mem- 
branes of  the  brain.  Fracture  of  this  part  also 
has  been  associated  with  very  copious  escape  of 
cerebro-spinal  fluid  through  the  nostrils.  A  men- 
ingocele may  protrude  through  the  nasal  roof. 
Tn  a  case  reported  by  Lichtenberg  the  mass  hung 
from  the  mouth,  having  passed  through  a  congeni- 
tal fissure  in  the  palate.  It  was  mistaken  for  a 
polyp,  was  ligatured,  and  death  resulted  from 
intracranial  inflammation. 

The  septum  is  seldom  quite  straight  in 
adults;  the  deviation  being  more  often  towards 
the  left.  .  It  is,  however,  straight  in  children, 
and  remains  so  up  to  the  seventh  year.  In  adults 
the  septuin  deviates  in  76  per  cent,  of  all  persons. 
The  deviation  may  follow  an  injury.  It  has  been 
pointed  out  that  a  deviation  of  the  septum  may 
seriously  interfere  with  the  singing  voice.  The 
nose  also  is  seldom  quite  straight,  and  French 
authors  ascribe  this  to  some  deviation  of  the  sep- 
tum, often  dependent  upon  the  practice  of  always 
blowing  the  nose  with  the  same  hand.  If  the 
deviation  of  the  septum  be  considerable,   it  may 


VII  NASAL    OUTER    WALL  105 

more  or  less  block  one  nostril,  and,  until  the  oppo- 
site nostril  is  examined,  be  mistaken  for  a  septal 
tumour  encroaching  upon  the  cavity.  The  flat- 
tened nose  in  acquired  syphilis  is  usually  due 
to  destruction  of  the  septum  and  more  or  less 
implication  of  the  adjacent  bones. 

Outer  wall  (Fig.  25). — The  inferior  turbin- 
ated bone  may  interfere  with  the  introduction  of 
a  Eustachian  catheter  if  the  curve  of  the  instru- 
ment be  too  great.  The  anterior  end  of  the  bone 
is  about  |  of  an  inch  behind  the  orifice  of  the 
nostril.  The  opening  of  the  nasal  duct  is  about 
1  inch  behind  the  orifice  of  the  nostril,  and  about 
|  of  an  inch  above  the  nasal  floor.  This  opening 
is  usually  slit-like  and  narrow.  The  nasal  duct 
pierces  the  nasal  mucous  membrane  in  the  same 
oblique  and  valvular  manner  as  the  ureter  enters 
the  bladder.  The  height  of  the  inferior  meatus  is 
about  |  of  an  inch.  The  superior  meatus  is  a 
very  short  and  narrow  fissure,  and  into  its  upper 
and  fore  part  open  the  posterior  ethmoidal  cells. 
The  middle  meatus  opens  widely  in  front  upon  a 
part  of  the  outer  wall  called  the  atrium,  and 
unless  care  be  taken  to  keep  the  point  of  any  in- 
strument well  towards  the  floor  of  the  fossa,  it 
is  easier  to  pass  the  instrument  into  the  middle 
than  into  the  inferior  meatus.  Upon  the  wall  of 
the  middle  meatus  is  a  deep  gutter  (the  hiatus 
semilunaris),  which  runs  from  above  downwards 
and  backwards  (Fig.  25).  Into  this  groove  open 
the  infundibulum  (the  aperture  of  the  frontal 
sinus)^  the  anterior  ethmoidal  cells,  and,  near  its 
posterior  end,  the  antrum.  The  rounded  aperture 
of  the  frontal  sinus  is  usually  situated  in  the 
anterior  end  of  the  hiatus,  but  not  infrequently 
it  will  be  found  in  a  recess  above  and  in  front  of 
the  hiatus.  The  anterior  ethmoidal  cells,  usually 
two  in  number,  may  open  into  the  hiatus,  the 
infundibulum,  or  directly  into  the  anterior  part 
of  the  middle  meatus.  The  opening  of  the  antrum 
may  occur  below,  instead  of  within,  the  posterior 
part   of   the   hiatus   semilunaris    (Fig.    25).      The 

E* 


106 


THE    HEAD    AND    NECK 


[Chap. 


upper  boundary  of  the  hiatus  is  formed  by  the 
bulla  ethmoidalis ;  its  lower  sharp  prominent 
margin  contains  the  uncinate  process  of  the  eth- 
moid. The  middle  ethmoidal  cell  is  seen  to  open 
on  the  bulla,  above  the  hiatus  semilunaris.  The 
level  of  the  hiatus  within  the  nose  may  be  indi- 
cated by  the  position  of  the  internal  tarsal  liga- 
ment.    The  anterior  end  or  beak  of  the  middle 


Aey  Fossa 

rtCMDAL  Sl/^US 


P/IARVAICCALTOAiSIL    I 

Lateral  Recess    j 

Eustachian  Tube     [ 

_\  EUSTACHIAN  Cusnio/i 

4-  Atlas 
Soft  Palate 


Fig.  25. — Outer  wall  of  the  nasal  cavity. 

The  greater  part  of  the  middle  turbinate  process  has  been  cut  away 
to  expose  the  hiatus,  bulla,  and  openings.  A,  B,  indicate  the  two 
positions  at  which  the  opening  of  the  antrum  may  occur. 


turbinate  process  can  be  seen  distinctly  from  the 
anterior  nares,  when  the  interior  of  the  nose  is 
illuminated   by    reflected   light. 

The  width  of  the  nasal  floor  is  about  J  an 
inch,  or  a  little  over.  Its  smooth  surface  greatly 
favours  the  passage  of  instruments  (Fig.  24).  It 
presents  a  gentle  slope  from  before  backwards. 
At  its  anterior  part  is  a  depression  of  mucous 
membrane  over  the  incisor  foramen.   This  foramen 


VI]  NASAL    MUCOUS    MEMBRANE  107 

is  a  vestige  of  the  great  communication  that 
once  existed  between  the  cavities  of  the  nose  and 
mouth. 

The  mucous  membrane  lining  the  nasal  cavi- 
ties is  covered  with  ciliated  epithelium  over  the 
lower  two-thirds  or  respiratory  part;  the  upper 
third — the  olfactory  part — is  covered  with  colum- 
nar epithelium,  while  the  vestibule  is  lined  with 
stratified  epithelium.  It  is  very  thick  and  vas- 
cular over  the  turbinate  bones  and  over  the  lower 
two-thirds  of  the  septum,  while  over  the  nasal 
floor  and  in  the  intervals  between  the  turbinate 
bones  it  is  very  much  thinner.  The  mucous 
membrane  lining  the  various  sinuses  and  the 
antrum  is  conspicuously  thin  and  pale.  The 
membrane  is  provided  with  many  glands,  which 
are  most  conspicuous  over  the  lower  and  hinder 
parts  of  the  outer  wall  and  over  the  posterior 
and  inferior  parts  of  the  septum.  These  glands 
may  be  the  subject  of  considerable  hypertrophy. 
They  are  capable  of  providing  also  a  very  copious 
watery  secretion,  which  has  in  some  cases  of 
chronic  coryza  following  injury  been  so  free  as 
to  be  mistaken  for  an  escape  of  cerebro-spinal 
fluid.  There  is  also  much  adenoid,  or  lymphoid 
tissue  in  the  nasal  mucous  membrane,  which 
is  the  primary  seat  of  the  chief  scrofulous  affec- 
tions that  invade  this  part.  So  thick  and  lax 
is  the  normal  mucous  membrane  over  the  lower 
border  and  posterior  extremity  of  the  inferior 
turbinated  bones  that  it  forms  a  kind  of  soft 
cushion,  sometimes  called  the  "  turbinate  body." 
This  condition  is  mainly  due  to  the  presence  of  a 
rich  submucous  venous  plexus,  the  vessels  of  which 
run,  for  the  most  part,  in  an  antero-posterior 
direction.  When  turgid  with  blood  it  swells  so 
as  to  obliterate  the  interval  between  the  bone  and 
the  septum.  When  the  seat  of  chronic  inflam- 
mation, the  mucous  membrane  over  the  inferior 
bone  may  appear  as  a  polypoid  swelling. 

Polypi  are  often  met  with  in  the  nose.  They 
are    of   two   kinds,    the    mucous   or   myxomatous 


108  THE    HEAD    AND    NECK  IChap. 

polyp  that  springs  usually  from  the  mucous  mem- 
brane beneath  or  over  the  middle  turbinate,  and 
the  fibrous  or  sarcomatous  polyp  that  usually 
takes  origin  from  the  periosteum  of  the  nasal 
roof  or  from  that  of  the  base  of  the  skull.  Polypi 
of  the  latter  kind  spread  in  every  available  direc- 
tion. They  expand  the  bridge  of  the  nose,  close 
the  nasal  duct  and  cause  epiphora,  depress  the 
hard  palate  and  encroach  upon  the  mouth,  in- 
vade the  antrum  and  expand  the  cheek,  grow 
down  into  the  pharynx,  pushing  forwards  the 
velum  palati,  and  may  penetrate  even  through  the 
inner  wall  of  the  orbit.  Such  tumours  may  be 
exposed  and  removed  by  separating  the  posterior 
and  inner  attachments  of  the  superior  maxilla, 
turning  it  forwards,  thus  exposing  the  nasal 
cavity  by  detaching  its  outer  wall.  The  bone  may 
be  replaced  in  situ  after  removal  of  the  tumour 
(F.  S.  Eve). 

The  blood  supply  of  the  nasal  cavity  is 
extensive,  and  is  derived  from  the  internal 
maxillary,  ophthalmic,  and  facial  arteries.  With 
regard  to  the  veins,  it  may  be  noted  that  the 
ethmoidal  veins  that  come  from  the  nose  enter  the 
ophthalmic  vein,  while  in  children  a  constant  com- 
munication exists  between  the  nasal  veins  and  the 
superior  longitudinal  sinus  through  the  foramen 
caecum.  This  communication  may  also  be  main- 
tained in  the  adult.  i  These  connexions  may,  in 
part,  serve  to  explain  the  occurrence  of  intra- 
cranial mischief  as  a  consequence  of  certain 
inflammatory  affections  of  the  nasal  cavities. 
Bleeding  from  the  nose,  or  epistaxis,  is  a  common 
and  often  a  serious  circumstance.  Its  frequency 
is  to  a  great  extent  due  to  the  vascularity  of  the 
mucous  membrane,  to  its  laxity,  and  to  the  fact 
that  the  veins,  especially  those  over  the  lowest 
turbinate  bone,  form  extensive  plexuses,  and  pro- 
duce a  kind  of  cavernous  tissue.  The  epistaxis  is 
often  due,  therefore,  to  interference  with  the 
venous  circulation,  as  seen  in  cases  of  cervical 
tumour    pressing    upon    the   great   veins,    in    the 


VIJ        NERVE    SUPPLY    OF    NASAL    CAVITY       109 

paroxysms  of  whooping  cough,  and  the  like:  The 
beneficial  effect  of  raising  the  arms  in  epistaxis 
is  supposed  to  depend  upon  the  extra  expansion 
of  the  thorax  thus  produced,  and  the  aspiratory 
effect  thus  brought  to  bear  upon  the  cervical  veins. 
The  bleeding  may  be  copious  and  long  continued. 
Thus,  Spencer  Watson  reports  a  case  where  the 
epistaxis  continued  on  and  off  for  twenty  months 
without  obvious  cause.  Martineau  mentions  an 
instance  in  which  12  lb.  of  blood  was  lost  in  sixty 
hours,  and  Fraenkel  records  a  case  where  75  lb. 
of  blood  is  said  to  have  escaped  from  first  to 
last.  In  several  instances  the  haemorrhage  has 
proved  fatal.  The  seat  of  the  bleeding  is  often 
not  easy  to  detect,  even  when  the  examination  is 
post-mortem.  In  many  cases  the  bleeding  point 
is  situated  on  the  septum,  \  an  inch  above  and 
behind  the  nasal  spine. 

The  nerve  supply  of  these  parts  is  derived 
from  the  olfactory  nerve,  and  from  the  first  and 
second  divisions  of  the  fifth  nerve.  The  lachryma- 
tion  that  often  follows  the  introduction  of  irri- 
tants into  the  front  of  the  nares  may  be  explained 
by  the  fact  that  that  part  of  the  cavity  is  sup- 
plied freely  by  the  nasal  nerve,  a  branch  of  the 
ophthalmic  trunk.  As  an  example  of  transfer- 
ence of  nerve  force  in  the  opposite  direction  may 
be  noted  cases  where  a  strong  sunlight  falling 
upon  the  eyes  has  produced  an  attack  of  sneez- 
ing. Troubles  involving  the  vagal  centres,  such 
as  cough  and  bronchial  asthma,  have  followed 
affections  of  the  nasal  cavities.  The  olfactory 
nerves  are  situated  in  the  upper  third  of  the 
cavity,  and  thus,  in  smelling  intently,  the  indi- 
vidual sniffs  deeply  and  dilates  the  nostril.  The 
inability  to  dilate  the  nostril  in  facial  paralysis 
may  explain  the  partial  loss  of  smell  sometimes 
noted  in  such  cases.  It  is  said  (Althaus)  that 
anosmia,  or  loss  of  the  sense  of  smell,  when  fol- 
lowing upon  an  injury  to  the  head,  may  be  due  to 
a  rupture  of  the  olfactory  nerve  fibres  as  they  pass 
through  the  cribriform  foramina.     The  olfactory 


110  THE    HEAD    AND    NECK  [Chap. 

roots  cross  the  edge  of  the  lesser  wings  of  the 
sphenoid,  and  in  falls  on  the  forehead  are  liable 
to  injury.  The  olfactory  centre  is  situated  in  the 
hippocampal  gyrus. 

Most  of  the  lymphatics  of  the  nasal  fossos 
enter  the  retropharyngeal  glands  placed  behind 
the  pharynx,  in  front  of  the  rectus  capitis  anticus 
major.  Hence,  as  Fraenkel  has  pointed  out, 
"  retropharyngeal  abscess  may  arise  in  conse- 
quence of  diseases  of  the  nose."  Other  lympha- 
tics go  to  the  submaxillary,  parotid,  and  upper 
deep  cervical  lymph-glands,  and  it  is  common  to 
find  these  enlarged  in  nose  affections,  especially  in 
the  scrofulous.  The  lymphatics  of  the  nose  also 
communicate  with  those  of  the  meninges  through 
the  cribriform  plate. 

Nasal  sinuses. — Of  late  years  a  knowledge 
of  the  anatomy  and  relationships  of  the  ac- 
cessory sinuses  of  the  nose  has  become  of  the 
utmost  importance  to  the  surgeon.  Over  15  per 
cent,  of  the  subjects  examined  in  the  dissecting 
room  of  the  London  Hospital  show  disease  of  one 
or  more  of  these  sinuses;  StClair  Thomson,  quot- 
ing from  German  statistics,  estimates  ^  that  the 
sphenoidal  sinus  is  the  seat  of  disease  in  30  per 
cent,  of  individuals— probably  an  overstatement. 
The  collective  capacity  of  the  accessory  sinuses — 
the  maxillary,  frontal,  sphenoidal,  and  ethmoidal 
— is  more  than  twice  that  of  the  nasal  cavity 
(Braune). 

The  frontal  sinus  is  extremely  variable  in 
size  and  shape.  The  surface  markings  shown  in 
Fig.  26  indicate  the  average  development  in  the 
adult;  the  opening  of  its  duct  or  infundibulum 
is  shown  in  Fig.  25.  Large  frontal  sinuses  do 
not  necessarily  imply  large  external  prominences 
over  the  glabella  and  superciliary  eminences.  One 
sinus  may  develop  at  the  expense  of  the  other, 
and  the  septum  may  be  displaced.  They  are 
larger  in  men  than  in  women.  They  are  absent 
on  one  side  in  9  per  cent,  of  cases,  and  on 
both    sides   in    7    per    cent.    (Logan    Turner).      It 


VI] 


FRONTAL    SINUS 


111 


is  obvious  that  a  depressed  fracture  may  exist 
over  a  frontal  sinus  without  the  cranial  cavity 
being    damaged.      In    such   cases   the    inspissated 


i  Fro/ital  Siaus 

AlASIOfl 


1/iFU/NDlBULUM 

Lacai.Sac 


/*!  id. Turbinate- 
/Iasal  Duct 


Aaitrum 

l/IF- TURBIAI ATE- 


Fig.  26. — Surface  markings  of  the  frontal  and  maxillary 
sinuses. 

A,  li  "  above  nasion  ;  B,  on  the  supra-orbital  margin,  at  the  junction 
of  the  middle  and  outer  thirds  ;  C,  on  the  infra-orbital  margin  to 
the  outer  side  of  the  lachrymal  sac  ;  D,on  the  centre  of  the  cheek 
bone  in  line  with  the  outer  margin  of  the  orbit ;  E,  over  the 
second  bicuspid  ;  F,  over  the  last  molar.  The  points  A,  B,  and 
Nasion  give  the  surface  position  of  the  frontal  sinus  ;  c,  D,  E,  F, 
that  of  the  maxillary  sinus. 

contents  of  the  sinus  have  been  mistaken  for 
brain  matter  escaping.  Since  the  sinuses  are  in 
communication  with  the  nose,  much  emphysema 
may  follow  upon  the  fracture  of  the  sinus  wall. 


1V2  THE    HEAT)    AND    NECK  [Chap. 

Insects  have  found  their  way  into  these  cavities. 
"  Centipedes  are  particularly  liable  to  be  found 
in  tne  frontal  sinuses,  where  they  may  remain  for 
years,  the  secretions  of  these  cavities  furnishing 
them  with  sufficient  nourishment "  (Fraenkel). 
Larvae  have  also  been  found  here,  and  maggots 
that  have  developed  within  the  nose  have  managed 
to  make  their  way  to  the  frontal  sinuses. 

The  frontal  sinus  is  absent  in  early  childhood. 
About  the  sixth  year  a  bud  of  mucous  membrane 
grows  out  from  the  anterior  end  of  the  hiatus,  and 
gradually  insinuates  its  growing  extremity  into 
the  diploe  of  the  frontal  bone,  separating  the 
inner  from  the  outer  osseous  table.  It  reaches  its 
full  size  about  the  twenty-fifth  year;  the  stalk  of 
the  outgrowth  becomes  the  infundibulum;  it  leads 
from  the  posterior  part  of  the  sinus.  The  infundi- 
bulum is  |  of  an  inch  long,  and  runs  downwards 
and  slightly  backwards  to  open  at  or  near  the 
anterior  end  of  the  hiatus  semilunaris.  Along  the 
hiatus  the  secretion  of  the  frontal  sinus  may  be 
conveyed  to  the  antrum,  thus  converting  that 
cavity  into  a  cesspool  in  cases  of  chronic  suppura- 
tion of  the  frontal  sinus  (Fig.  25).  The  infundi- 
bulum is  frequently  tortuous,  and  even  after  the 
beak  of  the  middle  turbinate  process  is  removed 
it  is  not  easy  to  catheterize  from  below.  Hence  in 
cases  of  obstruction  the  frontal  sinus  is  trephined 
over  the  glabella,  or  at  the  superior  internal  angle 
of  the  orbit  (Tilley),  and  a  probe  passed  down- 
wards and  slightly  backwards  to  drain  the  sinus 
into  the  nose. 

The  anterior  ethmoidal  cells  commonly  open 
into  the^  infundibulum,  and  hence  they  are 
usually  involved  in  any  disease  affecting  the 
frontal  sinus.  The  frontal  diploic  vein,  which 
joins  the  frontal  vein  at  the  supra-orbital  notch, 
receives  blood  from  the  frontal  sinus.  In  cases 
of  frontal  suppuration,  infection  may  spread 
rapidly  in  the  frontal  bone  by  means  of  the 
veins  of  the  diploe,  setting  up  a  destructive  form 
of  osteitis  and  meningitis. 


VI]  SPHENOIDAL    SINUS  113 

The  sphenoidal  sinus  opens  on  the  roof  of 
the  nose  behind  the  superior  meatus;  it  is  de- 
veloped at  the  same  period  of  life  as  the  frontal 
sinus  (.Fig.  25).  It  is  deeply  placed,  and  not  very 
accessible  for  operation  when  the  seat  of  disease. 
It  is  frequently  the  seat  of  chronic  suppuration 
set  up  by  infections  from  the  nose.  Its  anterior 
wall,  which  is  comparatively  thin,  is  situated  be- 
tween 7  and  8  cm.  from  the  lower  margin  of  the 
anterior  nares.  Tilley  recommends  the  mid  point 
of  the  lower  border  of  the  middle  turbinate  as  a 
guide  to  the  opening  of  the  sphenoidal  sinus. 
The  nasal  septum  also  serves  as  a  safe  guide,  for 
its  vomerine  part  is  implanted  on  the  anterior 
wall  of  the  sinuses.  A  probe  passed  to  this 
point  from  the  floor  of  the  anterior  nares  will, 
if  passed  straight  onwards,  reach  the  opening 
of  the  sinus  at  the  depth  mentioned  above — 
7  to  8  cm. 

In  close  contact  with  the  thin  lateral  wall  of  this 
sinus  there  are  certain  extremely  important  struc- 
tures. Besides  the  cavernous  sinus  and  internal 
carotid  artery,  the  optic  nerve  and  second  division 
of  the  fifth  nerve  are  in  the  closest  contact,  and 
may  be  affected  in  sinusitis  (Fig.  30).  On  the 
roof  is  the  pituitary  body ;  tumours  of  this 
body  may  invade  the  sinus.  Its  veins  join  the 
ethmoidal.  The  walls  of  the  sinuses  are  thin  and 
easily  perforated,  as  the  following  case,  which 
occurred  at  the  London  Hospital,  will  show.  A 
man  stumbled  forwards  on  his  umbrella  as  he 
left  a  public-house  in  Whitechapel,  the  point 
entering  his  face  above  the  bicuspid  teeth.  He 
walked  to  the  hospital,  and  died  three  days  after- 
wards. The  ferrule  of  the  umbrella  was  found 
embedded  in  the  pons,  the  point  having  traversed 
the  antrum  of  Highmore  and  the  sphenoidal 
sinus. 

The  antrum  exists  at  birth,  but  attains  its 
largest  dimensions  in  old  age.  The  surface  mark- 
ings for  indicating  its  position  on  the  face  are 
given   in    Fig.    26.     The   walls   of   the   cavity   are 


114  THE    HEAD    AND    NECK  [Chap. 

thicker  in  children  than  in  adults.  Tumours  of 
various  kinds  are  apt  to  develop  in  this  cavity, 
and  to  distend  its  walls  in  various  directions. 
Thus  the  growth  breaks  through  the  thin  inner 
wall  and  invades  the  nose,  it  pushes  up  the  roof 
of  the  cavity  and  invades  the  orbit,  it  encroaches 
upon  the  mouth  through  the  floor  of  the  antrum, 
and  makes  its  way  also  through  the  somewhat 
slender  anterior  wall  into  the  cheek.  The  densest 
part  of  the  antrum  wall  is  that  in  relation  to  the 
malar  bone,  and  this  part  does  not  yield.  There 
is  little  inducement  for  any  growth  to  spread 
backwards,  although  it  sometimes  invades  the 
zygomatic  and  ptery go-maxillary  fossae.  As  the 
infra-orbital  nerve  runs  along  the  roof  of  the 
antrum,  while  the  nerves  of  the  upper  teeth 
are  connected  with  its  walls,  these  structures  are 
pressed  upon  in  growths  springing  from  the 
antrum,  and  thus  neuralgia  of  the  face  and  teeth 
is  often   produced. 

In  the  operation  of  tapping  the  antrum  a  spot 
is  usually  selected  just  above  the  second  bicus- 
pid tooth,  since  the  bone  is  here  thin  and  is  con- 
veniently reached.  In  some  cases  it  is  sufficient 
to  extract  one  of  the  molar  teeth,  since  the  fangs 
of  these  often  enter  the  cavity  of  the  antrum.  The 
tooth  usually  selected  is  either  the  first  or  the 
third  molar.  Not  infrequently  the  antrum  com- 
municates at  its  upper  anterior  part  with  the 
frontal  sinus.  From  Fig.  24  it  will  be  seen  that 
the  antra  descend  below  the  level  of  the  palate, 
and  cannot  be  efficiently  drained  by  an  opening 
made  above  the  palatal  level. 

The  opening  of  the  antrum  is  shown  in  Figs.  24, 
25 ;  it  is  on  a  level  with  the  roof  of  the  cavity  : 
hence  if  pus  be  present  it  drains  most  freely  when 
the  head  is  turned  so  that  the  affected  chamber 
is  uppermost;  the  sphenoidal  sinus  empties  most 
easily  when  the  head  is  bent  forwards ;  the  frontal, 
when  the  head  is  thrown  backwards.  The  cavity 
of  the  antrum  is  small  if  the  inferior  meatus  is 
large  or  if  the  canine  fossa  of  the  face  be  well 


VI]  THE    ANTRUM  115 

marked.  The  lymphatics  of  the  sinuses  drain 
into  the  retropharyngeal  glands.  As  the  result  of 
a  fall,  one  of  the  upper  teeth  has  been  entirely 
driven  into  the  antrum  and  lost  to  view.  In  one 
case,  reported  by  Haynes  Walton,  an  upper  in- 
cisor was  found  lying  loose  in  the  antrum  three 
and  a  half  years  after  the  accident  that  had 
driven  it  there. 


CHAPTER    VJI 

THE    FACE 

The  parts  of  the  face,  other  than  those  already 
dealt  with,  will  be  considered  under  the  fol- 
lowing heads:  (1)  The  face  generally;  (2)  the 
parotid  region;  and  (3)  the  upper  and  lower 
jaws,  and  parts  connected  with  them.  The  lips 
will  be  considered  with  the  cavity  of  the  mouth 
(Chap.  viii.). 

1.    The  Face  Geneeally 

The  skin  of  the  face  is  thin  and  fine,  and 
is  more  or  less  intimately  adherent  by  a  deli- 
cate subcutaneous  tissue  to  the  parts  beneath. 
The  skin  generally  is  very  freely  supplied  with 
sebaceous  and  sudoriparous  glands,  and  hence 
the  face  is  very  commonly  the  seat  of  acne,  an 
eruption  that  specially  involves  the  sebaceous 
follicles.  It  happens  from  the  thinness  of  the 
skin,  and  from  the  absence  of  dense  fasciae,  that 
facial  abscesses  usually  soon  point  and  seldom 
attain  large  size. 

The  cellular  tissue  of  the  face  is  lax,  and 
readily  lends  itself  to  spreading  infiltrations,  so 
that  in  certain  inflammatory  affections  the  cheeks 
and  other  parts  of  the  face  may  become  greatly 
swollen.  In  general  dropsy,  also,  the  face  soon 
becomes  "  puffy/'  the  change  first  appearing  as 
a  rule  in  the  lax  tissue  of  the  lower  lid.  The 
skin  over  the  chin  is  peculiarly  dense  and  adherent 
to  the  parts  beneath,  and  in  most  respects  closely 
116 


Chap.  VII]     BLOOD    SUPPLY    OF    THE    FACE         117 

resembles  the  integument  of  the  scalp.  When  such 
parts  of  the  integuments  of  the  face  as  cover 
prominent  bones,  such  as  the  malar  bone,  chin, 
and  the  supra-orbital  margin,  are  struck  by  a 
blunt  instrument  or  in  a  fall,  the  wound  pro- 
duced has  often  the  appearance  of  a  clean  incised 
wound,  just  as  obtains  in  contused  wounds  of  the 
scalp. 

The  mobility  of  the  facial  tissues  renders  this 
part  very  suitable  for  the  performance  of  plastic 
operations  of  various  kinds,  and  their  vascularity 
generally  ensures  a  ready  and  sound  healing. 
Although  there  is  a  large  quantity  of  fat  in  the 
subcutaneous  tissue  of  this  region,  yet  fatty 
tumours  are  singularly  rare  upon  the  face.  They 
appear,  indeed,  to  avoid  this  region.  Thus,  M. 
Denay  reports  the  case  of  a  man  who  had  no  fewer 
than  215  fatty  tumours  over  different  parts  of 
his  body,  but  not  one  upon  his  face.  The  face  is 
peculiarly  liable  to  be  the  seat  of  certain  ulcers, 
especially  rodent  and  lupoid  ulcers,  and  is  the 
part  most  often  attacked  by  "  malignant  pustule/' 
a  disease  transmitted  to  man  from  cattle  afflicted 
with  a  malady  known  in  this  country  as  "  mur- 
rain, V  and  in  France  as  "  charbon.;y 

Blood  supply. — The  tissues  of  the  face  are 
very  vascular,  and  are  liberally  supplied  with 
blood-vessels  in  all  parts.  The  finer  vessels  of  the 
skin  often  appear  permanently  injected  or  vari- 
cose in  the  drunken,  or  in  those  who  are  exposed 
to  cold,  or  are  the  subjects  of  certain  forms  of 
acne.  Thus  nsevi  and  the  various  forms  of  erec- 
tile tumour  are  common  about  the  face.  #  For  a 
like  reason  also  wounds  of  the  face,  while  they 
may  bleed  readily  when  inflicted,  are  apt  to  heal 
with  singular  promptness  and  accuracy.  All 
wounds,  therefore,  of  this  part  should  have  their 
edges  carefully  adjusted  as  soon  after  the  accident 
as  possible.  Extensive  flaps  of  skin  that  have 
been  torn  up  in  lacerated  wounds  often  retain 
their  vitality  in  almost  as  marked  a  manner  as 
do    like    flaps    torn    from    the    scalp.      Extensive 


118  THE    HEAD    AND    NECK  [Chap. 

injuries  to  the  face  associated  with  great  loss 
of  substance  are  often  repaired  in  a  remarkable 
manner,  nor  may  such  injuries  be  immediately 
fatal,  as  a  case  reported  by  Longmore  shows  : 
"An  officer,  of  Zouaves,  wounded  in  the  Crimea, 
had  his  whole  face  and  lower  jaw  carried  away 
by  a  ball,  the  eyes  and  tongue  included,  so  that 
there  remained  only  the  cranium,  supported  by 
the  neck  and  spine.' '     He  lived  twentv  hours. 

The  pulsations  of  the  facial  artery  can  be  best 
felt  at  the  lower  border  of  the  jaw,  where  the 
vessel  crosses  just  in  front  of  the  anterior  border 
of  the  masseter  muscle.  It  is  here  covered  only 
by  the  integument  and  platysma,  and  can  be 
readily  compressed  against  the  bone  or  ligatured. 
The  anastomoses  of  the  artery  upon  the  face  are 
so  free  that  when  the  vessel  is  divided,  both  ends, 
as  a  rule,  require  to  be  secured.  The  facial  vein 
is  only  in  contact  with  the  artery  near  the  lower 
border  of  the  jaw ;  on  the  face  it  is  separated  from 
it  by  a  considerable  interval.  The  vein  is  not  so 
flaccid  as  are  most  superficial  veins;  it  remains 
more  patent  after  section,  it  possesses  no  valves, 
and  communicates  at  one  end  indirectly  with  the 
cavernous  sinus,  and  at  the  other  with  the  inter- 
nal jugular  vein  in  the  neck.  This  vein  has  also 
another,  but  less  direct,  communication  with  the 
intracranial  veins.  It  is  as  follows  :  the  facial  vein 
receives  the  "  deep  facial  vein  "  from  the  ptery- 
goid plexus,  and  this  plexus  communicates  with 
the  cavernous  sinus  by  means  of  some  small  veins 
which  pass  through  the  foramen  ovale  and  the 
fibrous  tissue  of  the  foramen  lacerum  medium. 
These  dispositions  of  the  facial  vein  may  serve 
to  explain  the  mortality  of  some  inflammatory 
affections  of  the  part.  Thus  carbuncle  of  the  face 
is  not  infrequently  fatal  by  inducing  thrombosis 
of  the  cerebral  sinuses,  and  a  like  complication 
may  occur  in  any  other  diffuse  and  deeply  extend- 
ing inflammatory  condition.  The  unusual  patency 
also  of  the  facial  vein  favours  septic  absorption, 
and  its  direct  communication  with  the  great  vein 


VII]  BLOOD    SUPPLY    OF    THE    FACE  119 

in  the  neck  may  explain  those  abrupt  deaths  from 
thrombosis  that  have  followed  upon  the  injection 
of  facial  nsevi  in  infants. 

A  reference  to  the  development  of  the  face 
assists  to  explain  the  distribution  of  the  fifth 
nerve  and  the  occurrence  of  certain  abnormalities 
(Fig.  27).  The  face  is  developed  from  five  pro- 
cesses, a  mesial,  the  fronto-nasal,  and  two  lateral 
— the   maxillary   and   mandibular.        The   fronto- 


Fig.  27.  —  Showing  the  development  of  the  face.      {Modified 
from  Merkel.) 

F.N.  P. ,  Part  formed  from  the  fronto-nasal  process  :  L.,  from  its  lateral, 
and  M.,  from  its  mesial  parts  ;  MAX.,  formed  by  the  maxillary 
process  ;  MAN.,  formed  by  the  mandibular  process. 

nasal  process  forms  the  middle  part  of  the  upper 
lip  and  the  nose.  It  may  fail  to  develop  :  thus 
the  condition  of  cyclops  is  produced.  It  springs 
from  the  frontal  region  and  carries  with  it  a 
branch  of  the  first  division  of  the  fifth,  the  nasal 
nerve.  The  second  division  of  the  fifth  is  the 
nerve  of  the  maxillary  process,  while  the  third  is 
that  of  the  mandibular. 

Nerve    supply. — The   nerves  of   the   face  are 
very    liberally    distributed,    the    fifth    being    the 


120  THE    HEAD    AND    NECK  [Chap. 

sensory  nerve,  the  facial  the  motor  (Fig.  4,  p.  15). 
It  follows,  from  the  great  number  of  nerve  fila- 
ments about  the  part,  and  the  extensive  sensory 
nucleus  of  the  fifth  nerve,  that  severe  irritants 
applied  to  the  face  may  set  up  a  widespread  nerve 
disturbance.  Dr.  George  Johnson  mentions  a  case 
where  a  piece  of  flint  embedded  in  a  scar  on  the 
cheek  set  up  facial  neuralgia,  facial  paralysis, 
and  trismus,  and  induced  a  return  of  epileptic 
attacks.  The  positions  of  the  supra-  and  infra- 
orbital foramina  and  of  the  mental  foramen  and 
of  the  exit  of  the  corresponding  nerves  are  indi- 
cated as  follows  :#  The  supra-orbital  foramen  is 
found  at  the  junction  of  the  inner  with  the  middle 
third  of  the  upper  margin  of  the  orbit.  A  straight 
line  drawn  downwards  from  this  point  so  as  to 
cross  the  gap  between  the  two  bicuspids  in  both 
jaws  will  cross  both  the  infra-orbital  and  mental 
foramina.  The  infra-orbital  foramen  is  a  little 
over  J  of  an  inch  below  the  margin  of  the  orbit. 
The  mental  foramen  in  the  adult  is  midway  be- 
tween the  alveolus  and  the  lower  border  of  the 
jaw,  and  is  a  little  over  J  of  an  inch  below  the 
cul-de-sac  of  mucous  membrane  between  the  lower 
lip  and  jaw.  At  puberty  the  foramen  is  nearer 
to  the  lower  border  of  the  maxilla,  and  in  old  age 
it  is^  close  to  the  alveolus.  The  inf ra=orbital  nerve 
has  been  divided  for  neuralgia  at  its  point  of  exit, 
the  nerve  being  reached  either  by  external  incision 
or  through  the  mouth  by  lifting  up  the  cheek.  In 
other  cases  the  floor  of  the  orbit  has  been  exposed, 
the  infra-orbital  canal  (the  anterior  half  of  which 
has  a  bony  roof)  has  been  opened  up,  and  large 
portions  of  the  trunk  of  the  nerve  have  been  in 
this  way  resected.  Meckel's  jrangflion  has  been 
repeatedly  excised  for  the  relief  of  neuralgia  in- 
volving the  second  division  of  the  fifth  nerve.  A 
triangular  flap  of  skin  is  turned  up  from  the  front 
of  the  cheek,  and  the  infra-orbital  foramen  is  ex- 
posed. The  anterior  wall  of  the  antrum  is  opened 
with  a  trephine,  and  the  bone  is  cut  away  from 
the  floor  of  the  infra-orbital  groove  so  that  the 


VII]      EXCISION    OF    MECKEL'S    GANGLION        121 

nerve  lying  in  that  canal  is  fully  exposed.  The 
nerve  is  followed  back  to  the  posterior  wall  of  the 
antrum.  This  wall  haying  been  trephined,  the 
spheno-maxillary  fossa  is  opened  up  and  Meckel's 
ganglion  exposed.  Beyond  the  ganglion  the  fora- 
men rotundum  can  be  made  out.  The  infra-orbital 
artery  runs  with  the  nerve,  and  that  vessel,  to- 
gether with  its  anterior  dental  branch  to  the 
incisor  and  canine  teeth,  will  probably  be  divided. 


Artic.  Tuber 

3RD     DiV. 

Ext.   P7£hygoid   Plate 

Spheno-Max.   Fossa 


Fig.  28. — Surface^markings  for  the  second  and  third 
divisions  of  the  fifth  nerve. 


The  infra-orbital  yein^  ends  in  the  pterygoid 
plexus.  The  ganglion  is  surrounded  by  the  ter- 
minal branches  of  the  internal  maxillary  artery. 
It  is  a  triangular  body,  with  a  diameter  of  about 
J  of  an  inch.  It  is  a  little  convex  on  its  outer 
side,    and   is   of   reddish  colour. 

Operations  such  as  that  just  described  serve  to 
recall  the  relationship  of  parts,  but  in  practice 
they  are  now  replaced  by  the  simpler  means 
of   hypodermic   injections.     Absolute   alcohol,    in- 


122  THE    HEAD    AND    NECK  [Chap. 

troduced  into  the  trunk  of  a  nerve,  produces 
anaesthesia  in  the  area  of  its  distribution  for  six 
months  or  more.  The  successful  performance  of 
such  injections  requires  a  very  accurate  knowledge 
of  the  position  and  course  of  the  nerves,  and 
also  of  surrounding  structures.  The  course  of 
the  second  division  of  the  fifth  nerve  is  shown 
in  Fig.  28.  A  point  on  the  upper  border  of  the 
zygoma,  6  mm.  (J  inch)  behind  the  ascending 
margin  of  the  malar,  lies  directly  over  the  upper 
part  of  the  spheno-maxillary  fissure  which  con- 
tains the  second  division  of  the  fifth  nerve  and 
Meckel's  ganglion.  To  reach  the  nerve  the  needle 
has  to  be  introduced  37  mm.  (lj  inches).  An 
easier  and  safer  route  is  along  the  floor  of  the 
orbit.  The  needle  is  inserted  at  the  mid-point  of 
the  lower  border  of  the  orbit,  and  pushed  back- 
wards along  the  floor,  parallel  to  the  sagittal 
plane  of  the  head.  The  needle  enters  the  spheno- 
maxillary fissure  and  fossa  until  it  is  arrested 
by  coming  in  contact  with  the  sphenoid  at  or  near 
the  foramen  rotundum.  By  suitable  manoeuvring 
the  needle  can  be  felt  to  enter  the  foramen 
rotundum.  The  depth  of  the  foramen  rotundum 
from  the  margin  of  the  orbit  is  43  mm.  (If  inches). 
The  nerve  may  also  be  reached  by  introducing  the 
needle  below  the  zygoma  and  directing  it  upwards 
and  inwards,  but  there  is  a  grave  risk  of  injuring 
the  optic  nerve  if  the  needle  should  be  thrust  too 
far  inwards. 

The  inferior  dental  nerve  has  been  divided 
at  the  mental  foramen  by  an  incision  made 
through  the  buccal  mucous  membrane.  Through 
this  incision  the  nerve  can  be  stretched  and  the 
cutaneous  portion  of  it  excised.^  Its  trunk  has 
been  reached,  and  a  part  excised,  through  .  a 
trephine  hole  made  in  the  body  of  the  lower  jaw. 
This  operation,  however,  inflicts  great  damage 
upon  the  bone,  and  cannot  be  recommended.  The 
artery,   moreover,   is  liable  to  be^  wounded. 

The  nerve  has  been  divided  in  the  following 
manner  before  its  entry  into  the  mental  foramen  : 


VII]  NERVE    SUPPLY    OF    THE    FACE  123 

The  mouth  being  held  widely  open,  an  incision  is 
made  from  the  last  upper  molar  to  the  last  lower 
molar  just  to  the  inner  side  of  the  anterior  bor- 
der of  the  coronoid  process,  which  can  be  clearly 
defined  by  palpation.  The  cut  passes  through  the 
mucous  membrane  down  to  the  tendon  of  the  tem- 
poral muscle.  The  finger  is  introduced  into  the 
incision,  and  passed  between  the  ramus  of  the 
jaw  and  the  internal  pterygoid  muscle  until 
the  bony  point  is  felt  that  marks  the  orifice  of 
the  dental  canal.  The  nerve^  is  here  picked  up 
with  a  hook,   isolated,   and  divided. 

The  buccal  nerve  supplies  the,  mucous  membrane 
and  skin  of  the  cheek.  It  passes  forwards  on 
the  outer  surface  of  the  buccinator  muscle. 

The  trunk  of  the  third  division  of  the  fifth 
nerve  leaves  the  middle  fossa  of  the  skull  by  the 
foramen  ovale,  the  position  of  which  corresponds 
to  the  lower  border  of  the  zygoma  immediately 
anterior  to  the  eminentia  articularis  (Fig.  28). 
To  inject  the  trunk  of  the  nerve,  the  needle  is 
entered  at  this  point  and  guided  inwards  against 
the  under  surface  of  the  sphenoid  until  a  depth 
of  37  mm.  (l\  inches)  is  reached.  Sensations 
referred  along  the  nerve  will  tell  the  operator 
if  the  nerve  has  been  reached.  It  is  well  to 
direct  the  needle  a  little  forwards  as  well  as 
inwards,  for  it^  will  be  then  arrested  by  the 
external  pterygoid  plate;  at  the  posterior  border 
of  this  plate  lies  the  foramen  ovale. 

When  a  sensory  nerve  is  divided  the  area 
of  analgesia  which  results  <  does  not  correspond 
to  its  anatomical  distribution.  Thus,  when  the 
ophthalmic  division  of  the  fifth  cranial  nerve  is 
cut,  only  a  narrow  strip  of  skin  on  the  forehead  is 
completely  deprived  of  feeling,  whereas  from  the 
anatomical  distribution  one  would  infer  that  the 
skin  of  the  forehead  and  of  the  anterior  half  of  the 
scalp  shouklbe  involved  (see  Fig.  4,  p.  15).  If  the 
second  division  is  cut,  the  area  of  anaesthesia  is 
confined  to  a  narrow  space  between  the  orbit  and 
the  mouth;  on  section  of  the  third  division,  to  a 


124 


THE    HEAD    AND    NECK 


[Chap. 


strip  running  downwards  in  front  of  the  ear  and 
along  the  course  of  the  lower  jaw  (Head). 

Head  has  offered  an  explanation  of  the  vary- 
ing results  which  follow  section  of  a  sensory 
nerve.  A  nerve  contains  three  kinds  of  sensory 
nerve  fibres  :  (1)  those  subserving  deep  sensibility 
— endowing  muscles,  bones,  ligaments,  joints,  and 
deep  structures  with  the  power  to  feel  pressure  and 
pain;  (2)  those  subserving  protopathic  sensibility  — 
by  which  the  skin  is  rendered  sensitive  to  prick 


Fig.  29. — The  extent  of  loss  of  sensibility  following  (A) 
excision  of  the  Gasserian  ganglion,  (B)  section  of  the 
second  cervical  nerve.     {After  II.  E.  Tooth.) 

In  the  area  stippled  black  there  is  a  loss  of  protopathic  sensibility  ; 
in  that  stippled  red,  of  epicritic  sensibility. 

and  to  temperature,  if  it  be  above  40°  or  below 
22°;  (3)  those  subserving  epicritic  sensibility— by 
which  the  skin  is  endowed  with  the  power  of  feel- 
ing light  touch  (tested  with  such  a  substance  as 
cotton-wool)  and  finer  degrees  of  temperature. 
Now,  in  the  majority  of  instances,  when  a  nerve  is 
divided,  the  loss  of  epicritic  sensibility  corresponds 
in  extent  to  the  anatomical  distribution  of  the 
nerve;  when  the  Gasserian  ganglion  is  removed 
{see  Figs.  4  and  29)  the  loss  of  epicritic  sensibility 
corresponds  to  the  area  of  distribution,  but  the  loss 


VII       EXCISION    OF    GASSEEIAN    GANGLION      125 

of  protopathic  sensibility  is  less  than  the  anatomi- 
cal area.  It  is  evident  that  protopathic  fibres  from 
the  second  cervical  nerve  (Fig.  29)  invade  and  sup- 
ply the  area  of  skin  furnished  with  epicritic  sen- 
sibility by  the  fifth  nerve.  In  the  lower  part  of  the 
face  there  is  no  overlapping  of  areas  ;  in  the  mental 
branch  of  the  fifth,  the  epicritic  and  protopathic 
fibres  are  distributed  to  the  same  extent  of  skin. 
Thus  the  effects  which  follow  section  of  a  sensory 


Island  of  Ceil  & 
Fissure  oe  Sylviu: 
Deep  Temp.  Fascia 

Temp.  Muscle 
First  Te/ip.  Fissure 
Uncus 
Dura  mater 
/liD.flEriiMQEAL  Art- 
Root  of  zvqoma 
Ext  Ptervqoid 
Aid  AlENi/iqEAL  Art 
Int.  Max.  Art 
Masseter 
CCRONOlD   Proc 


Optic  Tract 
Subarachnoid  Space 

Cavernous  Sinus 
hT  Carotid  Art 
Vlfb 

Qasserian  CJanqlion 
Sphenoidal  Sinus 
3rd  Div  of  V^h 
Lat  RecessofPhar. 
Eustachian  Tube.- 
Levator  Palatae 


Fig.  30. — Coronal   section   to  show  the  depth  and 
relationships  of  the  Gasserian  ganglion. 


nerve  depend  on  the  nature  of  the  fibres  in  that 
nerve,  and  on  the  extent  of  skin  to  which  each 
kind  is  exclusively   distributed. 

Excision  of  the  Gasserian  ganglion. — For  cases 
of  intolerable  and  intractable  neuralgia  Rose  pro- 
posed the  excision  of  the  Gasserian  ganglion.  It 
is  the  sensory  ganglion  of  the  fifth  nerve,  and  cor- 
responds to  the  ganglion  on  the  posterior  root  of  a 
spinal  nerve.  The  nerve  fibres  of  the  fifth  neces- 
sarily undergo  degeneration  when  it  is  excised- 

The  operation  usually  performed  is  the  follow- 


126  THE    HEAD    AND    NECK  [Chap. 

ing  (see  Fig.  30)  :  An  omega-shaped  flap  of  skin  is 
raised  from  the  temples,  having  the  zygoma  at 
its  base  and  the  temporal  ridge  at  its  convexity. 
The  tissues  are  reflected  down  to  the  floor  of  the 
temporal  fossa.  The  superficial  and  deep  temporal 
vessels  have  to  be  tied.  A  wide  trephine  opening  is 
made  in  the  squamosal  and  great  wing  of  the 
sphenoid  on  a  level  with  the  upper  border  of  the 
zygoma,  and  the  dura  mater  exposed.  This  is 
usually  followed  by  profuse  haemorrhage  from  the 
middle  meningeal  vessels  which  cross  the  field  of 
operation.  The  dura  mater  and  the  superimposed 
temporo-sphenoidal  lobe  are  raised  from  the  bone, 
when  the  third  and  second  divisions  of  the  fifth 
nerve  are  brought  into  view  as  they  escape  by  the 
foramen  ovale  and  foramen  rotundum.  They  are 
seen  to  spring  from  the  Gasserian  ganglion  situ- 
ated over  the  apex  of  the  petrous  bone  and  on  the 
outer  wall  of  the  cavernous  sinus.  The  motor  root 
which  supplies  the  muscles  of  mastication  lies 
under  the  ganglion  and  should  not  be  cut.  The 
ganglion  is  embedded  in  the  dura  mater  and  sur- 
rounded by  a  prolongation  of  the  subarachnoid 
space  (Meckel's  space),  which  is  necessarily  opened. 
Only  the  part  of  the  ganglion  connected  with  the 
second  and  third  divisions  is  removed,  the  part 
connected  with  the  ophthalmic  division  being  left, 
as  it  is  firmly  embedded  in  the  outer  wall  of  the 
cavernous  sinus  and  in  close  proximity  to  the  inter- 
nal carotid  artery  and  the  oculo-motor  nerves. 
The  hippocampal  convolution  containing  the  olfac- 
tory centre  lies  immediately  over  the  ganglion 
(Fie:.  30). 

The  eminentia  articularis  at  the  base  of  the 
zygoma  serves  as  a  useful  guide  to  the  position 
of  the  ganglion  ;  when  the  middle  fossa  is  opened 
and  the  temporal  lobe  raised  up  the  ganglion  will 
be  found  at  a  depth  of  2j  inches  and  in  the  same 
coronal  plane  as  the  articular  eminence,  but  at  a 
higher  level.* 

*  For  a  full  account  of  the  anatomy  of  this  operation  see  "The  Surgical 
Treatment  of  Facial  Neuralgia,"  by  J,  Hutchinson,  jun,    Jjopflon,  J9Q5, 


VII]  PAROTID    GLAND  127 

Malar  bone. — Such  is  the  firmness  of  this 
bone,  and  so  direct  is  itsconnexion  with  the  skull, 
that  violent  blows  upon  it  are  very  apt  to  be  asso- 
ciated with  concussion.  Resting  as  it  does  upon 
comparatively  slender  bones,  it  is  very  rare  for  the 
malar  bone  to  be  broken  alone.  It  may,  indeed,  be 
driven  into  the  superior  maxillary  bone,  fracturing 
that  structure  extensively,  without  being  itself  in 
any  way  damaged.  A  fracture  of  the  malar  bone 
may  lead  to  an  orbital  ecchymosis,  precisely  like 
that  which  often  attends  a  fracture  of  the  skull 
base. 

2.   The  Parotid  Region 

The    main    part    of    the    parotid    gland    is 

lodged  in  a  definite  space  behind  the  ramus  of 
the  lower  jaw  (Fig.  31).  This  space  is  increased 
in  size  when  the^  head  is  extended,  and  when 
the  inferior  maxilla  is  moved  forwards,  as  in 
protruding  the  chin.  In  the  latter  movement 
the  increase  in  the  antero-posterior  direction  is 
equal  to  about  f  of  an  inch.  It  is  diminished  when 
the  head  is  flexed.  When  the  mouth  is  widely 
opened  the  space  is  diminished  below,  while  it  is 
increased  above  by  the  gliding  forwards  of  the  con- 
dyle. These  facts  should  be  borne  in  mind  in 
operating  upon  and  in  exploring  the  parotid  space. 
It  will  be  found  also  that  in  inflammation  of  the 
parotid  much  pain  is  produced  by  all  those  move- 
ments that  tend  to  narrow  the  space  occupied  by 
the  gland.  The  obliquity  of  the  ramus  of  the  jaw 
in  infancy  and  old  age  causes  the  lower  part  of  the 
space  to  be,  in  the  former  instance  relatively  and 
in  the  latter  instance  actually,  larger  than  it  is 
in  the  adult. 

The  gland  is  closely;  invested  by  a  fascia  derived 
from  the  cervical  fascia.  The  superficial  layer  of 
the  parotid  fascia  is  very  dense,  continuous  be- 
hind with  the  fibrous  sheath  of  the  sterno-mastoid, 
and  in  front  with  that  of  the  masseter.  Aboye^  it 
is  attached  to  the  zygoma,  while  below  it  Joins 
the   deep   layer.    The   fleep   layer   is   slender,    is 


128 


THE    HEAD    AND    NECK 


[Chap. 


attached  to  the  styloid  process,  forms  the  stylo- 
maxillary  ligament,  and  is  connected  with  the 
sheaths  of  the  pterygoid  muscles  and  the  pterygoid 
process.      The   gland    is,    therefore,    encased   in   a 

distinct  sac  of  fascia, 
which  is  entirely  closed 
below,  but  is  open  above. 
Between  the  anterior 
edge  of  the  styloid  pro- 
cess and  the  posterior 
border  of  the  internal 
pterygoid  muscle  there 
is  a  gap  in  the  fascia, 
through  which  the  paro- 
tid space  communicates 
with  the  connective  tis- 
sue about  the  pharynx. 
It  is  well  known  that 
in    postpharyngeal    ab- 

Fig.  31.  — Horizontal  section 
through  one  side  of  the  face 
and  neck  just  above  the 
level   of  the   lower   teeth. 

{Braune.) 
a,  Facial  artery  ;  &,  facial  vein  :  <*, 
gustatory  nerve  ;  d,  inferior 
dental  nerve  and  artery  lying 
internally  to  the  ascending 
ramus  of  jaw  ;  <?,  stvloid  pro- 
cess :  /.  internal  carotid  artery  ; 
gr,  internal  jugular  vein,  with 
the  va=ms,  spinal  accessory, 
and  hypoglossal  nerves  to  its 
inner  side  ;  h.  vertebral  artery. 
Externally  to  the  ascending 
ramus  is  shown  the  masseter  ; 
internally  to  it  the  internal 
pterygoid :  internallv  to  the 
last-named  muscle,  the  supe- 
rior constrictor  and  tonsil. 

scesses  there  is  very  usually  a  parotid  swelling 
and  in  several  instances  the  pus,  or  at  least  some 
portion  of  it,  has  been  evacuated  in  the  parotid 
region.  In  these  cases  the  matter  most  probably 
extends  from  the  pharyngeal  to  the  parotid  region 


VII]  PAROTID    ABSCESS  129 

through  the  gap  just  described.  From  the  disposi- 
tion of  the  fascia  it  follows  that  very  great  resist- 
ance is  offered  to  the  progress  of  a  parotid  abscess 
directly  outwards  through  the  skin.  The  abscess 
often  advances  upwards  to  the  temporal,  or  zygo- 
matic fossae,  in  the  direction  of  least  resistance,  al- 
though progress  in  that  line  is  resisted  by  gravity. 
It  frequently  makes  its  way  towards  the  buccal 
cavity  or  pharynx,  or  it  may  break  through  the 
lower  limits  of  the  fascia  and  reach  the  neck.  It 
must  be  borne  in  mind  that  the  gland  is  in  direct 
contact  with  the  cartilaginous  meatus,  with  the 
ramus  of  the  jaw  and  other  bony  parts,  and  is 
closely  related  to  the  temporo-maxillary  joint. 
Thus,  a  parotid  abscess  has  burst  into  the  meatus, 
has  led  to  periostitis  of  the  bones  adjacent  to  it, 
and  has  incited  inflammation  in  the  joint  of  the 
lower  jaw. 

In  several  cases  reported  by  Virchow  the  pus 
appears  to  have  found  its  way  into  the  skull  along 
branches  of  the  fifth  nerve,  for  the  environs  of  the 
Gasserian  ganglion  were  found  infiltrated  with 
pus.  The  auriculo-temporal  and  great  auricular 
nerves  supply  the  gland  with  sensation,  and  the 
presence  of  these  nerves,  together  with  the  unyield- 
ing character  of  the  parotid  fascia,  serves  to  ex- 
plain the  great  pain  felt  in  rapidly  growing 
tumours  and  acute  inflammation  of  the  gland. 
The  pain  is  often  very  distinctly  referred  along 
the  course  of  the  auriculo-temporal  nerve.  Thus, 
a  patient  with  parotid  growth  under  my  care 
had  pain  in  those  parts  of  the  pinna  and  temple 
supplied  by  the  nerve,  pain  deep  in  the  meatus,  at 
a  spot  that  would  correspond  to  the  entrance  of 
the  meatal  branch  of  the  nerve,  and  pain  in  the 
joint  of  the  lower  jaw,  which  is  supplied  by  the 
auriculo-temporal. 

The  most  important  structures  in  the  gland 
are  the  external  carotid  artery,  with  its  two 
terminal  branches,  and  the  facial  nerve.  The 
external  carotid  artery,  as  Tillaux  has  pointed 
out,  is  behind  the  ramus  of  the  jaw,  as  high 
F 


130 


THE    HEAD    AND    NECK 


[Chap. 


up  as  the  junction  of  the  inferior  with  the 
middle  third  of  its  posterior  border.  It  then 
enters  the  parotid  gland,  and,  passing  a  little 
backwards  and  outwards,  comes  nearer  to  the 
surface,  and  at  the  level  of  the  condyle  of  the  jaw 
breaks  into  its  two  terminal  branches.  The  artery, 
therefore,  does  not  enter  the  gland  at  its  inferior 
border,    and    is   not   in    actual    relation    with    the 


5up  Temp.Art. 
Ext.  AuDiTORy/lEAius 

IrtF.AlAX.ART 

^Styloid  Proc. 
Facial  /Ierve 

Spiaial  Accessory  /I. 


/Iypoqlossal  N. 
5TE-/sso/i's  Duct 
y-ExT  Carotid  Art 
/Diqastric 


sc.  /Iypoclossi 
Facial  Art. 

li/ncual  Art 

AlyPOCLOSSAL  AlERVEr 

Qreat  ftotin  o/Alyoio 


fr 


Fig.  32. — Surface  markings  of  the  facial,  spinal  accessory, 
and  hypoglossal  nerves. 

A,  Mid-point  of  anterior  border  oi*  mastoid  process  ;  B,  point  on 
anterior  border  of  sterno-mastoid,  1  inch  below  mastoid  process  ; 
c,  mid-point  of  posterior  border  of  sterno-mastoid.  Above  B 
the  transverse  process  of  the  atlas  is  indicated. 

parotid  space  at  its  lowest  part.  The  vessel,  more- 
over, is  not  parallel  with  the  edge  of  the  ramus, 
but  passes  through  the  parotid  gland  with  some 
obliquity. 

At  its  point  of  exit  from  the  base  of  the 
skull  by  the  stylo-mastoid  foramen,  the  facial 
nerve  lies  1  inch  deep  to  the  mid-point  of  the 
anterior   border    of   the   mastoid   process;    a    line 


VII]         SECTION    OF    THE    FACIAL    NERVE         131 

drawn  horizontally  forwards  from  that  point  to 
the  posterior  border  of  the  ascending  ramus  of  the 
mandible  marks  the  position  of  the  main  trunk  of 
the  nerve  (Fig.  32).  Within  the  gland,  where  the 
nerve  divides  into  its  temporo-facial  and  cervico- 
facial divisions,  it  is  superficial  to  both  the  ex- 
ternal carotid  artery  and  temporo-maxillary  vc  m. 
The  nerve  has  been  stretched  close  to  its  point  of 
exit  from  the  stylo-mastoid  foramen  for  the  relief 
of  facial  tic.  It  is  best  found  at  a  spot  about  i  of 
an  inch  in  front  of  the  centre  of  the  anterior 
border  of  the  mastoid  process.  It  will  be  found 
above  the  posterior  belly  of  the  digastric,  which 
serves  as  a  guide  to  it  in  the  depth  of  the  wound. 

Section  of  the  facial  nerve  causes  paralysis  of 
the  buccinator  and  of  all  the  muscles  of  expres- 
sion, the  mouth  being  pulled  towards  the  sound 
side  and  the  eye  remaining  unclosed.  To  restore 
mobility  to  the  face  in  cases  of  palsy,  surgeons 
have,  in  a  number  of  instances,  sutured  the 
facial  to  the  trunk  of  a  neighbouring  nerve — 
the  trunks  selected  being  the  spinal  accessory  and 
hypoglossal  (Fig.  32).  In  the  one  case  the  muscles 
of  expression  are  thrown  into  action  when  the 
trapezius  and  sterno-mastoid  are  used;  in  the 
other  when  the  tongue  is  moved.  In  course  of  time 
the  patient  may  become  able  to  dissociate  these  in- 
conveniently combined  movements.  At  its  point 
of  exit  the  facial  nerve  gives  off  its  posterior 
auricular  branch  to  the  muscles  of  the  ear  and 
twigs  to  the  posterior  belly  of  the  digastric  and 
stylo-hyoid  muscles. 

It  follows,  from  the  complex  relations  of  the 
parotid,  that  its  entire  removal  as  a  surgical  pro- 
cedure is  an  anatomical  impossibility.  In  open- 
ing a  parotid  abscess  a  cut  is  usually  made  over  the 
angle  of  the  jaw,  and  a  director  pushed  upwards 
into  the  substance  of  the  gland,  after  the  plan  ad- 
vised by  Hilton.  The  gland  is  separated  by  a  mere 
layer  of  fascia  from  the  internal  carotid  artery,  the 
internal  jugular  vein,  the  vagus,  glosso-pharyn- 
geal,  and  hypoglossal  nerves  (Fig.  31)      Thus,  in 


132  THE    HEAD    AND    NECK  Chap. 

stabs  in  the  parotid  region  it  may  be  difficult  at 
first  to  tell  whether  the  internal  or  the  external 
carotid  is  wounded. 

Tumours  of  the  parotid  are  very  apt  to  contain 
cartilaginous  tissue.  It  is  well  known  that  metas- 
tases after  mumps  are  quite  common  in  the  testis. 
It  is  significant  in  this  connexion  that  the  testis  is 
one  of  the  few  parts  of  the  body,  apart  from  bone, 
where  cartilaginous  matter  forms  a  frequent  con- 
stituent of  the  neoplasms  of  the  part.  Mr.  Paget 
has  pointed  out  that  inflammation  of  the  parotid 
is  peculiarly  frequent  after  injuries  and  diseases 
of  the  abdomen  and  pelvis.  It  occurs  also  very 
often  as  a  sequela  of  some  specific  fevers,  but  more 
especially  after  typhoid.  The  anatomical  or  physio- 
logical basis  of  this  connexion  has  not  been  made 
out. 

Many  lymphatic  glands  are  placed  upon  the 
surface  and  in  the  substance  of  the  parotid  gland. 
They  receive  lymph  from  the  frontal  and  parietal 
regions  of  the  scalp,  from  the  orbit,  the  posterior 
part  of  the  nasal  fossae,  the  upper  jaw,  and  the 
hinder  and  upper  part  of  the  pharynx.  When 
enlarged,  these  glands  may  form  one  species  of 
" parotid  tumour." 

Stenson's  duct  (Fig.  32)  is  about  2j  inches 
long,  and  has  a  diameter  of  Jth  of  an  inch,  its 
orifice  being  the  narrowest  part.  At  the  anterior 
border  of  the  masseter  muscle  the  duct  bends 
suddenly  inwards  to  pierce  the  buccinator  muscle. 
The  bend  is  so  abrupt  that  the  buccal  segment  of 
the  duct  may  be  almost  at  right  angles  with  the 
masseteric.  This  bend  should  be  taken  into  con- 
sideration in  passing  a  probe  along  the  duct  from 
the  mouth.  The  duct  opens  on  the  summit  of  a 
papilla  placed  on  a  level  with  the  second  upper 
molar  tooth.  The  course  of  the  duct  across  the 
masseter  is  represented  by  a  line  drawn  from  the 
lower  margin  of  the  concha  to  a  point  midway 
between  the  ala  of  the  nose  and  the  red  margin  of 
the  lip.  It  lies  about  a  finger-breadth  below  the 
zygoma,  having  the  transverse  facial  artery  above 


VII]  SUPERIOR    MAXILLA  133 

it  and  the  infra-orbital  branches  of  the  facial  nerve 
below.  The  duct  has  been  ruptured  subcutane- 
ously,  leading  to  extravasations  of  saliva.  Wounds 
of  the  duct  are  apt  to  lead  to  salivary  fistulse. 
When  the  fistula  involves  the  buccal  segment  of 
the  duct  it  may  be  cured  by  opening  the  duct  into 
the  mouth  on  the  proximal  side  of  the  fistula. 
Fistulae  of  the  masseteric  segment  are,  on  the 
other  hand,  very  difficult  to  relieve.  At  least  one- 
half  of  the  buccal  part  of  the  duct  is  embedded  in 
the  substance  of  the  buccinator  muscle.  A  salivary 
fistula  over  the  masseter  may  involve  the  parotid 
gland  itself,  or  that  part  of  it  known  as  the  socia 
parotidis.  Inflammatory  conditions  may  spread 
to  the  parotid  from  the  mouth  along  Stenson's 
duct. 

3.  The  Upper  and  Lower  Jaws,  and  Parts 
connected  avith  them 

Superior  ma  villa  (for  antrum,  see  p.  113; 
for  hard  palate,  p.  155). — This  bone,  on  ac- 
count of  its  fragility  and  the  manner  in  which 
it  is  hollowed  out,  is  very  readily  fractured. 
The  bone  being  very  vascular,  serious  injuries, 
involving  great  loss  of  substance,  are  often 
wonderfully  repaired.  Its  hollowness,  and  the 
cavities  that  it  helps  to  bound,  render  it  pos- 
sible for  large  foreign  bodies  to  be  retained 
in  the  deeper  parts  of  the  face.  Thus,  Long- 
more  reports  "  the  case  of  Lieutenant  Fretz,  of 
the  Ceylon  Rifles,  who  was  able  to  do  his  mili- 
tary duties  for  nearly  eight  years  with  the  breech 
and  screw  of  a  burst  musket  lodged  in  the  nares, 
part  of  the  tail-pin  and  screw  protruding  through 
the  hard  palate  into  the  mouth. "  The  bone  may 
undergo  extensive  necrosis,  especially  in  that  form 
of  necrosis  induced  in  workers  in  match  factories 
by  exposure  to  the  fumes  of  phosphorus.  In  one 
case  (Med.  Time*  and  Gazette,  1862)  of  necrosis 
following  measles  the  mischief  was  limited  to  the 
premaxillary,  or  incisive  bone. 


131  THE    HEAD    AND    NECK  [Chap. 

The  periosteum  of  the  superior  maxilla  is,  like 
the  pericranium,  not  disposed  to  form  new  bone.  In 
ordinary  cases  of  necrosis  of  the  upper  jaw  no  re- 
production of  bone  takes  place,  the  gap  being  left 
permanent.  In  the  lower  jaw  abundant  new  bone 
is  produced  by  the  periosteum,  and  extensive 
losses  may  be  repaired.  It  is  remarkable,  however, 
that  in  course  of  years  this  new  bone  is  liable  to 
be  very  extensively  reabsorbed. 

Excision  of  the  superior  maxilla. — The  entire 
bone  has  been  frequently  removed  when  the  seat 
of  an  extensive  tumour,  and  under  certain  other 
conditions.  The  bony  connexions  to  be  divided 
in  the  operation  are  the  following  (see  Fig.  24, 
p.  102,  and  Fig.  28,  p.  121):  (1)  The  connexion 
with  the  malar  bone  at  the  outer  side  of  the 
orbit;  (2)  the  connexion  of  the  nasal  process 
with    the    frontal,    nasal    and    lachrymal    bones; 

(3)  the  connexions  of  the  orbital  plate  with  the 
ethmoid  and  palate  (this  plate  is  often  left#  be- 
hind, or  is  cut  through  near  the  orbital  margin)  ; 

(4)  the  connexion  with  the  opposite  bone  and 
the  palate  in  the  roof  of  the  mouth;  and  (5)  the 
connexion  behind  with  the  palate  bone,  and  the 
fibrous  attachments  to  the  pterygoid  processes.  In 
the  four  first-named  instances  the  separation  is 
effected  by  a  cutting  instrument ;  in  the  last- 
named,  by  simply  twisting  out  the  bone. 

Soft  parts  divided :  These  may  be  considered 
under  three  heads  :  The  parts  cut  (1)  in  the  first 
incision ;  (2)  in  turning  back  the  flap ;  and  (3)  in 
separating  the  bone. 

(1)  The  following  are  the  parts  cut,  in  order 
from  above  downwards,  in  the  usual,  or  "median," 
incision,  an  incision  commencing  parallel  with  the 
lower  eyelid,  and  continued  down  the  side  of  the 
nose,  round  the  ala,  and  through  the  middle  of 
the  upper  lip  :  Skin,  superficial  fascia,  orbicularis 
palpebrarum,  palpebral  branches  of  infra-orbital 
nerve  and  artery,  part  of  lev.  labii  super.,  angular 
artery  and  vein,  lev.  labii  sup.  alaeque  nasi,  later- 
alis nasi  artery  and  vein,  nasal  branches  of  infra- 


VII]  THE    MAXILLiE  135 

orbital  nerve,  compressor  naris,  depressor  alse  nasi, 
attachment  of  nasal  cartilage  to  bone,  orbicularis 
oris,  sup.  coronary  artery  and  vein,  and  mucous 
membrane  of  lip.  Various  branches  of  the  facial 
nerve  to  the  muscles  may  be  cut.  (2)  In  turning 
back  the  flap,  the  muscles  above  named  will  be 
dissected  up,  together  with  the  ten  do  oculi,  if  the 
nasal  process  is  removed  entire,  the  levator  anguli, 
the  buccinator,  a  few  fibres  of  the  masseter,  and, 
on  the  orbital  plate,  the  inferior  oblique  muscles. 
The  infra-orbital  nerve  and  artery  will  be  cut  as 
they  leave  their  foramen.  In  the  flap  itself  will  be 
the  trunks  of  the  facial  artery  and  vein,  the  trans- 
verse facial  artery,  and  the  facial  part  of  the  facial 
nerve.  (3)  In  separating  the  nasal  process  the  lach- 
rymal sac  and  infratrochlear  nerve  will  be  dam- 
aged, and  the  nasal  duct  and  external  branch  of 
the  nasal  nerve  cut  across.  In  separating  the  bones 
below,  the  coverings  of  the  hard  palate  are  divided, 
and  the  attachment  of  the  soft  palate  to  the 
palate  bone,  unless  the  removal  of  that  process 
can  be  avoided.  "  Any  attempt  to  dissect  off  and 
preserve  the  soft  covering  of  the  hard  palate  is 
futile "  (Heath).  Posteriorly,  the  trunk  of  the 
infra-orbital  nerve  is  again  divided  (this  time 
in  front  of  Meckel's  ganglion),  together  with 
the  posterior  dental  and  infra-orbital  arteries, 
and  some  branches  of  the  spheno-palatine  artery. 
The  deep  facial  vein  from  the  pterygoid  plexus 
will  probably  be  cut,  and,  lastly,  near  the  palate 
will  also  be  divided  the  large  palatine  nerve  and 
the  descending  palatine  artery. 

It  will  be  seen  that  no  large  artery  is  divided  in 
the  operation.  The  inferior  turbinated  bone  comes 
away,   of  course,  with  the  maxilla. 

Inferior  maxilla. —This  bone  is  to  a  great 
extent  protected  from  fracture  by  its  horse-shoe 
shape,  which  gives  it  some  of  the  properties  of  a 
spring,  by  its  density  of  structure,  by  its  great 
mobility,  and  by  the  buffer-like  interarticular 
cartilages  that  protect  its  attached  extremities. 
The   bone    is    usually   broken    by    direct   violence, 


136  THE    HEAD    AND    NECK  [Chap. 

and  the  fracture  may  be  in  any  part.  The  sym- 
physis is  rarely  broken,  on  account  of  its  great 
thickness.  The  ramus  is  protected  by  the  muscu- 
lar pads  that  envelop  its  two  sides,  and  the  coro- 
noid  process  is  still  more  out  of  the  risk  of  injury, 
owing  to  the  depth  at  which  it  is  placed  and  the 
protection  it  derives  from  the  zygoma.  The  weak- 
est part  of  the  bone  is  in  front,  where  its  strength 
is  diminished  by  the  mental  foramen  and  by  the 
large  socket  required  for  the  canine  tooth.  It  is 
about  this  part,  therefore,  that  fracture  is  the  most 
common.  The  bone  may  be  broken  near,  or  even 
through,  the  symphysis  by  indirect  violence,  as  by 
a  blow  or  crushing  force  that  tends  to  approximate 
the  two  rami.  Thus,  the  jaw  has  been  broken  near 
the  middle  line  by  a  blow  in  the  masseteric  region. 
The  amount  of  displacement  in  fractures  of  this 
bone  varies  greatly,  and  is  much  influenced  by  the 
nature  and  direction  of  the  force.  In  general 
terms,  it  may  be  said  that  when  the  body  of  the 
bone  is  broken  the  anterior  fragment  is  drawn 
backwards  and  downwards  by  the  jaw  depressors, 
the  digastric,  mylo-hyoid,  genio-hyoid,  and  genio- 
hyo-glossus  ;  while  the  hinder  fragment  is  drawn 
up  by  the  elevators  of  the  jaw,  the  masseter,  inter- 
nal pterygoid,  and  temporal.  It  must  be  remem- 
bered that  the  mylo-hyoid  muscle  will  be  attached 
to  both  fragments,  and  will  modify  the  amount  of 
displacement.  Fractures  of  the  ramus  are  seldom 
attended  with  much  displacement,  muscular  tissue 
being  nearly  equally  attached  to  both  fragments. 

In  fractures  of  the  body  of  the  bone  the  dental 
nerve  often  marvellously  escapes  injury,  a  fact  that 
is  explained  by  the  supposition  that  the  bones  are 
not  usually  sufficiently  displaced  to  tear  across  the 
nerve.  Weeks  after  the  accident,  however,  the 
nerve  has  become  so  compressed  by  the  developing 
callus  as  to  have  its  function  destroyed. 

One  or  both  condyles  have  often  been  broken 
by  falls  or  blows  upon  the  chin.  The  gums  being 
firm  and  adherent,  it  follows  that  they  are  usually 
torn  in  fractures  of  the  body  of  the  maxilla,  and 


VII]  TEMPORO-M  AXILLARY    JOINT  137 

hence  the  bulk  of  the  fractures  in  this  part  are 
compound. 

The    temporo  -  maxillary    articulation    is 

supported  by  a  capsule  which  varies  greatly  in 
thickness  in  different  parts.  By  far  the  thickest 
part  of  the  capsule  is  the  external  part  (the  exter- 
nal lateral  ligament).  The  internal  part  is  next  in 
thickness,  while  the  anterior  and  posterior  por- 
tions of  the  capsule  are  thin,  especially  the  former, 
which  is  very  thin.  Thus,  when  this  joint  suppu- 
rates, the  pus  is  least  likely  to  escape  on  the  ex- 
ternal aspect  of  the  articulation,  and  is  most  likely 
to  find  an  exit  through  the  anterior  part  of  the  cap- 
sule, although  this  part  is  to  a  great  extent  pro- 
tected by  the  attachments  of  the  external  ptery- 
goid muscle.  Immediately  behind  the  condyle  of 
the  jaw  are  the  bony  meatus  and,  a  little  to  the 
inner  side,  the  middle  ear.  In  violent  blows  upon 
the  front  of  the  jaw  these  structures  may  be  dam- 
aged, and  it  is  interesting  to  note  that  the  strongest 
ligament  of  the  joint  (the  external  lateral)  has  a 
direction  downwards  and  backwards,  so  as  im- 
mediately to  resist  any  movement  of  the  condyle 
towards  the  slender  wall  of  bone  that  bounds  the 
meatus  and  tympanum.  Were  it  not  for  this  liga- 
ment, a  blow  upon  the  chin  would  be  a  much  more 
serious  accident  than  it  is  at  present. 

The  movements  of  this  joint  are  peculiar.  On 
opening  the  mouth  it  will  be  observed  that  the 
condyle  moves  forwards  and  downwards  upon  the 
articular  eminence,  while  the  angle  of  the  jaw 
moves  in  a  backward  and  upward  direction.  The 
axis  of  the  movement  is  a  transverse  line  drawn 
between  the  inferior  dental  foramina ;  thus,  it  will 
be  seen  that  the  inferior  dental  nerves  enter  the 
mandible  at  the  point  of  least  movement.  The  ex- 
ternal pterygoid  muscles,  by  pulling  the  condyle 
upon  the  articular  eminence,  take  the  chief  part 
in  opening  the  mouth  ;  at  the  same  time  the  chin 
is  depressed  by  the  contraction  of  the  mylo-hyoid 
and  digastric  muscles. 

Dislocation — This    joint    permits    of    only    one 


138  THE    HEAD    AND    NECK  [Chap. 

form  of  dislocation,  a  dislocation  forwards.  It  may 
be  unilateral  or  bilateral,  the  latter  being  the  more 
usual,  and  it  can  only  occur  when  the  mouth  hap- 
pens to  be  wide  open.  Indeed,  the  dislocation  is 
nearly  always  due  to  spasmodic  muscular  action 
when  the  mouth  is  open,  although  in  some  few  cases 
it  has  been  brought  about  by  indirect  violence,  as 
by  a  downward  blow  upon  the  lower  front  teeth, 
the  mouth  being  widely  opened.  It  has  occurred 
during  yawning,  violent  vomiting,  etc.  In  more 
than  one  case  the  accident  happened  while  a 
dentist  was  taking  a  cast  of  the  mouth.  Hamilton 
quotes  a  bilateral  dislocation  in  a  woman  during 
the  violent  gesticulations  incident  to  the  pursuit 
of  scolding  her  husband.  When  the  mouth  is 
widely  opened,  the  condyles,  together  with  the 
interarticular  fibro-cartilage,  glide  forward.  The 
fibro-cartilage  extends  as  far  as  the  anterior  edge 
of  the  eminentia  articularis,  which  is  coated  with 
cartilage  to  receive  it.  The  condyle  never  reaches 
quite  so  far  as  the  summit  of  that  eminence.  All 
parts  of  the  capsule  save  the  anterior  are  rendered 
tense.  The  coronoid  process  is  much  depressed. 
Now  if  the  external  pterygoid  muscle  (the  muscle 
mainly  answerable  for  the  luxation)  contract  vigor- 
ously, the  condyle  is  soon  drawn  over  the  eminence 
into  the  zygomatic  fossa,  the  interarticular  carti- 
lage remaining  behind.  On  reaching  its  new  posi- 
tion it  is  immediately  drawn  up  by  the  temporal, 
internal  pterygoid,  and  masseter  muscles,  and  is 
thereby  more  or  less  fixed.  A  specimen  in  the 
Musee  Dupuytren  shows  that  the  fixity  of  the  lux- 
ated jaw  may  sometimes  depend  upon  the  catch- 
ing of  the  apex  of  the  coronoid  process  against 
the  malar  bone. 

Subluxation  of  the  jaw  is  a  name  given  to  a 
slight  and  quite  incomplete  dislocation  of  the  jaw 
not  infrequently  met  with  in  delicate  women.  It  is 
due  to  a  displacement  of  the  interarticular  carti- 
lage, and  can  be  cured  by  exposing  the  cartilage  and 
attaching  it  by  suture  to  the  fibrous  structures 
around  the  joint  (Annandale), 


VII]  EXCISION    OF    LOWER    JAW  139 

Excision  of  the  inferior  maxilla. — Considerable 
portions  of  the  lower  jaw  can  be  excised  through 
the  mouth  without  external  wound.  In  excising 
one  entire  half  of  the  miaxilla,  a  cut  is  made 
vertically  through  the  lower  lip  down  to  the  point 
of  the  chin,  and  is  then  continued  back  along  the 
inferior  border  of  the  jaw,  so  as  to  end  near  the 
lobule  of  the  ear,  after  having  been  carried  verti- 
cally  upwards  in  the  line  of  the  posterior  border 
of  the  ramus.  The  soft  parts  divided  may  be  con- 
sidered under  three  heads  :  Those  concerned  (1)  in 
the  first  incision  ;  (2)  in  clearing  the  outer  surface 
of  the  bone  ;  (3)  in  clearing  the  inner  surface  of  the 
bone. 

1.  (a)  In  the  anterior  vertical  cut:  Skin,  etc., 
orbicularis  oris,  inferior  coronary  and  inferior 
labial  vessels,  branches  of  submental  artery,  leva- 
tor menti,  mental  vessels  and  nerve,  some  radicles 
of  anterior  jugular  vein,  (b)  In  the  horizontal  cut : 
Skin,  etc.,  platysma,  branches  of  superficial  cer- 
vical nerve,  branches  of  supramaxillary  part  of 
facial  nerve,  facial  artery  and  vein  at  edge  of  mas- 
seter,  and  inframaxillary  branch  of  facial  nerve 
(not  necessarily  divided),  (c)  The  posterior  verti- 
cal incision  would  not  go  down  to  the  bone,  and 
would  merely  expose  the  surface  of  the  parotid 
gland  and  part  of  posterior  border  of  masseter 
muscle. 

2.  In  clearing  the  outer  surface  the  following 
parts  are  dissected  back  :  Levator  menti,  the  two 
depressor  muscles,  buccinator,  masseter  (crossed 
by  part  of  parotid  gland,  transverse  facial  vessels, 
facial  nerve,  and  Stenson's  duct),  masseteric  ves- 
sels and  nerve,  temporal  muscle. 

3.  In  clearing  the  inner  surface :  Digastric, 
genio-hyoid.  genio-hyo-glossus,  and  mylo-hyoid 
muscles,  a  few  fibres  of  superior  constrictor,  in- 
ternal pterygoid  muscle,  inferior  dental  artery 
and  nerve,  mylo-hyoid  vessels  and  nerve,  internal 
lateral  ligament,  rest  of  insertion  of  temporal 
muscle,  mucous  membrane. 

Parts  in  risk  of  being  damaged. — The   facial 


140  THE    HEAD    AND    NECK  [Chap, 

nerve,  if  the  posterior  vertical  incision  be  carried 
too  high  up.  The  internal  maxillary  artery, 
temporo-maxillary  vein,  auriculo-temporal  nerve 
(structures  all  closely  related  to  the  jaw  condyle), 
external  carotid  artery,  lingual  nerve,  the  parotid, 
submaxillary,  and  sublingual  glands.  After  sub- 
periosteal resection  the  entire  bone  has  been  re- 
produced. 

Deformities. — The  lower  jaw  may  be  entirely 
absent,  or  of  dwarfed  dimensions,  or  incompletely 
formed.  These  conditions  are  congenital,  and 
depend  upon  the  defective  development  of  the 
mandibular  or  first  visceral  arch,  out  of  which 
the  lower  jaw  is  formed  (Fig.  27,  p.  119).  They 
are  often  associated  with  branchial  fistulse,  super- 
numerary ears,  macrostoma,  and  like  congenital 
malformations. 

Nerves. — With  regard  to  the  nerves  connected 
with  the  jaws,  little  need  be  said.  The  upper  teeth 
are  supplied  by  the  second  division  of  the  fifth,  the 
lower  by  the  third.  Some  remarkable  nerve  dis- 
turbances have  followed,  by  reflex  action,  upon 
irritation  of  the  dental  nerves.  Thus  cases  of  stra- 
bismus, temporary  blindness,  and  wry-neck  have 
been  reported  as  due  to  the  irritation  of  carious 
teeth.  Hilton  gives  the  case  of  a  man  who  was 
much  troubled  by  a  carious  tooth  in  the  lower  jaw 
(supplied  by  the  third  division  of  the  fifth),  and 
who  developed  a  patch  of  grey  hair  over  the  region 
supplied  by  the  auriculo-temporal  nerve  (a  branch 
also  of  the  third  division).  The  roots  of  the  third 
lower  molar  are  in  close  proximity  to  the  dental 
canal,  and  hence  the  nerve  may  be  torn  if  this 
tooth  is  roughly  extracted.  The  roots  have  been 
seen  to  enclose  the  nerve. 

Caries  of  the  teeth  is  frequently  associated  with 
areas  of  hyperesthesia  on  the  side  of  the  face  and 
neck.  The  explanation  of  the  reflection,  to  cer- 
tain areas  of  skin,  of  pain  set  up  by  dental  caries 
must  be  sought  for  in  a  close  association  of  the 
central  nerve  nuclei,  in  which  the  cutaneous  and 
dental  nerves  terminate,    Disease  of  the  peridental 


VII  i  TRISMUS  141 

membrane  does  not  give  rise  to  referred  pains 
(Head). 

The  muscles  of  mastication  are  often  at- 
tacked by  spasm.  When  the  spasm  is  clonic,  chat- 
tering of  the  teeth  is  produced.  When  the  spasm  is 
tonic  the  mouth  is  rigidly  closed,  and  the  condi- 
tion known  as  trismus,  or  lockjaw,  is  produced. 
Trismus  is  among  the  first  symptoms  of  tetanus. 
It  is  also  very  apt  to  be  produced  by  irrita- 
tion of  any  of  the  sensory  branches  of  the  third 
division  of  the  fifth,  since  the  motor  nerve 
supply  of  the  muscles  themselves  is  derived 
from  that  trunk.  Thus  trismus  is  very  common 
in  caries  of  the  lower  teeth,  and  during  the 
"  cutting  "  of  the  lower  wisdom  tooth.  It  is 
much  less  common  in  affections  of  the  upper 
set  of  teeth,  since  they  are  supplied  by  a  more 
remote  division  of  the  fifth  nerve.  If  the  motor 
root  of  the  third  division  of  the  fifth  nerve 
be  cut  in  excising  the  Gasscrian  ganglion,  paralysis 
and  atrophy  overtake  the  muscles  of  mastication 
of  the  corresponding  side.  The  muscles  of  the 
sound  side,  however,  are  still  able  to  carry  on  the 
necessary  movements  of  the  jaw  concerned  in 
speech  and  mastication. 

Teeth, — As  a  test  of  age  the  following  periods 
for  the  eruption  of  teeth  are  given  by  Mr.  C. 
Tomes  :  m  Temporary  teeth:  Lower  central  incisors, 
six  to  nine  months ;  upper  incisors,  ten  months ; 
lower  lateral  incisors  and  four  first  molars,  a  few 
months  later ;  then,  after  a  rest  of  four  or  five 
months,  the  canines;  and,  lastly,  the  second 
molars;  the  whole  being  in  place  by  the  end  of  the 
second  year.  Permanent  teeth:  First  molars,  sixth 
or  seventh  year ;  next  in  order  the  lower  central 
incisors,  then  the  upper  central  incisors,  and  a 
little  later  the  laterals,  the  eighth  year ;  first  bicus- 
pids, ninth  or  tenth  year ;  second  bicuspids  and 
canines,  about  the  eleventh  year,  the  lower  preced- 
ing the  upper ;  the  second  molars,  the  twelfth  or 
thirteenth  year ;  the  wisdom  teeth,  eighteen  to 
twenty -five  or  later. 


142  THE    HEAD    AND    NECK  [Chap  VII 

An  alveolar  abscess  is  formed  about  the  fang 
of  a  tooth.  In  the  case  of  single-fanged  teeth 
the  pus  may  escape  along  the  groove  of  the  fang. 
With  other  teeth  the  pus  tends  to  pierce  the  al- 
veolus. If  the  point  of  the  fang  is  within  the  re- 
flection of  the  mucous  membrane  from  the  gum  to 
the  cheek  the  abscess  will  break  into  the  mouth, 
but  if  the  point  of  the  fang  is  without  that  reflec- 
tion, or  if  the  pus  can  gravitate  without  the  line 
of  reflection,  then  the  pus  may  break  through  the 
cheek.  Alveolar  abscess  of  the  upper  incisors  and 
canines  never  breaks  through  the  cheek.  When 
connected  with  the  upper  molars  it  sometimes 
does.  When  connected  with  any  of  the  lower 
teeth  the  abscess  may  find  its  way  through  the  skin 
of  the  cheek. 

The  upper  wisdom  tooth  is  developed  in  the 
posterior  border  of  the  upper  jaw,  and  the  lower 
wisdom  on  the  inner  aspect  of  the  ascending 
ramus.  They  may  fail  to  come  into  position  or  re- 
main buried.  They  may  give  rise  to  deeply-seated 
and  obscure  abscesses  ^  which  frequently  point  in 
the  neck,  at  some  distance  from  their  seat  of 
origin. 


CHAPTER    VIII 

THE  MOUTH,  TONGUE,  PALATE,   AND 
PHARYNX 

The  Mouth 

The  lips. — The  principal  tissues  composing  the 
lips  have  the  following  relation  to  one  another, 
proceeding  from  without  inwards  :  (1)  Skin ;  (2) 
superficial  fascia;  (3)  orbicularis  oris;  (4)  coron- 
ary vessels;  (5)  mucous  glands,  and  (6)  mucous 
membrane.  The  free  border  of  the  lip  is  very  sensi- 
tive, many  of  the  nerves  having  end  bulbs  closely 
resembling  tactile  corpuscles.  The  upper  lip  is 
supplied  with  sensation  by  the  second  division  of 
the  fifth  nerve,  and  the  lower  lip  by  the  third 
division.  Over  these  labial  nerves  a  crop  of  herpes 
often  appears  (herpes  labialis).  The  free  border 
of  the  lower  lip  is  more  frequently  the  seat  of 
epithelioma  than  is  any  other  part  of  the  body ;  its 
lymphatic  vessels  pass  to  the  submental  and  sub- 
maxillary lymphatic  glands  (Fig.  44,  p.  197).  The 
lips  contain  much  connective  tissue,  and  may  swell 
considerably  when  inflamed,  or  cedematous.  They 
are  very  mobile,  and  are  entirely  free  for  a 
considerable  extent  from  bony  attachment  of  any 
kind.  It  follows  that  destructive  inflammations  of 
the  lips,  and  such  losses  of  substance  as  accom- 
pany severe  burns,  produce  much  contraction  and 
deformity  of  the  f  mouth.  Contracting  cicatrices, 
also,  in  the  vicinity  of  the  mouth  are  apt  to  drag 
upon  the  lips,  everting  them  or  producing  kindred 
143 


144  THE    HEAD    AND    NECK  [Chap. 

distortions.  It  is  fortunate  that  the  laxity  of  the 
tissues  around  the  mouth,  and  the  general  vascu- 
larity of  the  part,  greatly  favour  the  success  of  the 
many  plastic  operations  performed  to  relieve  these 
deformities. 

The  lips  are  very  vascular,  and  are  often  the 
seat  of  nsevi  and  other  vascular  tumours.  The 
coronary  arteries  are  of  large  size,  and  their  pul- 
sations can  generally  be  felt  when  the  lip  is 
pinched  up.  These  vessels  run  beneath  the  orbi- 
cularis oris  muscle,  and  are  consequently  nearer 
to  the  mucous  membrane  than  they  are  to  the  skin. 
When  the  inner  surface  of  the  lip  is  cut  against 
the  teeth,  as  the  result  of  a  blow,  these  arteries 
are  very  apt  to  be  wounded.  As  such  wounds  are 
concealed  from  view,  the  consequent  haemorrhage 
has  sometimes  given  rise  to  an  erroneous  diag- 
nosis. Thus,  Erichsen  quotes  the  case  of  a  drunken 
man,  the  subject  of  such  a  wound,  who,  having 
swallowed,  and  then  vomited,  the  blood  escaping 
from  a  coronary  artery,  was  for  a  while  supposed 
to  be  suffering  from  an  internal  injury.  As  the 
anastomoses  between  the  arteries  of  the  lip  are 
very  free,  it  is  usually  necessary  to  tie  both  ends 
of  the  vessel  when  it  has  been  cut  across. 

The  mucous  glands  in  the  submucous  tissue  are 
large  and  numerous.  From  closure  of  the  ducts 
of  these  glands,  and  their  subsequent  distension, 
result  the  "mucous  cysts "  that  are  so  common 
about  the  lips.  "Hare-lip"  is  noticed  below  in 
connexion  with  the  subject  of  cleft  palate. 

Buccal  cavity.— The  following  points  may  be 
noticed  in  the  examination  of  the  interior  of 
the  mouth  :  In  the  floor  of  the  mouth,  on  either 
side  of  the  fraenum  linguae,  can  be  observed  the 
sublingual  papillae  with  the  openings  of  Whar- 
ton's ducts.  The  duct  of  Bartholin  (one  of  the 
ducts  of  the  sublingual  gland)  runs  along  the  last 
part  of  Wharton's  duct,  and  opens  either  with  it 
or  very  near  it.  Wharton's  duct  is  singularly 
indistensible,  and  hence  is  partly  explained  the 
intense  pain  usually  observed  when  that  duct  is 


VII1J 


BUCCAL    CAVITY 


145 


obstructed  by  a  calculus.  The  proximity  of  this 
duct  to  the  lingual  nerve  may  serve  also  to  ac- 
count for  the  pain  in  some  cases.  The  submaxil- 
lary gland  can  be  made  out  through  the  mucous 
membrane  at  a  point  a  little  in  front  of  the  angle 
of  the  jaw,  especially  when  the  gland  is  pressed 
up  from  the  outside.  On  the  floor  of  the  mouth, 
between  the  alveolus  and  the  anterior  part  of  the 
tongue,  is  a  well-marked  ridge  of  mucous  mem- 
brane, that  is  directed  obliquely  forwards  and  in 
wards  to  the  sublingual  papilla  near  the  frsenum 
(Fig.   33).     It  indicates  the   position   of  the  sub- 


CEmoflyo-CLOssui 


Sup.  LiicualiS 
l/^r«-Li/iCOALi& 

AyO-ClOSSus 
Li  /icual  Artery 
Subungual  Qland 
Sublingual  Artery 


CErtlO-rtYOID 
/IvLO-rtVOID 

Digastric 


Fig.  33. — Section  acros    tongue  and  mandible  to  show  the 
position   of  the   sublingual   gland    and    lingual  artery. 

{After  Poirier.) 


lingual  gland,  and  also,  so  far  as  it  goes,  the  line 
of  Wharton's  duct  and  the  lingual  nerve.  These 
structures,  with  the  sublingual  artery,  lie  beneath 
the  mucous  membrane  between  the  gland  and  the 
side  of  the  tongue.  The  ducts  of  the  sublingual 
gland,  some  ten  to  twenty  in  number,  open  into 
the  mouth  along  the  ridge  of  mucous  membrane 
just  referred  to.  Ranula,  a  cystic  tumour  filled 
with  mucous  contents,  is  often  met  with  over  the 
site  of  the  sublingual  gland,  and  is  due  to  the  dila- 
tation of  one  of  the  gland  ducts  that  has  become  ob- 
structed, or  to  an  occluded  mucous  follicle.  The 
mucous  membrane  of  the  floor  of  the  mouth,  as  it 
passes  forward  to  be  reflected  on  to  the  gums,  is 


146  THE    HEAD    AND    NECK  [Chap. 

attached  near  to  the  upper  border  of  the  jaw  (Fig. 
33).  Here  also  are  situated  some  mucous  glands 
which  may  become  cystic.  The  genio-hyo-glossus 
is  attached  near  the  lower  border.  Between  these 
two  parts  (the  mucous  membrane  and  the  muscle) 
there  is,  according  to  Tillaux,  a  small  space  lined 
with  squamous  epithelium.  To  this  cavity  the 
name  of  the  sublingual  bursa  mucosa  is  given. 
It  is  constricted  in  its  centre  by  the  f rsenum 
linguae,  and  is  said  to  be  the  seat  of  mischief  in 
"  acute  ranula." 

When  the  mouth  is  widely  opened  the  pterygo- 
maxillary  ligament  can  be  readily  seen  and  felt  be- 
neath the  mucous  membrane.  It  appears  as  a  pro- 
minent fold  running  obliquely  downwards  behind 
the  last  molar  teeth.  A  little  below  and  in  front 
of  the  attachment  of  this  ligament  to  the  lower 
jaw,  the  gustatory  nerve  can  be  felt  as  it  lies  close 
to  the  bone  just  below  the  last  molar.  At  this 
point  it  may  be  divided,  or  reached  by  the  needle 
of  a  syringe.  This  nerve,  as  it  lies  against  the 
bone,  has  been  crushed  by  the  slipping  of  the 
forceps  in  clumsy  extraction  of  the  lower  molar 
teeth. 

The  coronoid  process  of  the  lower  jaw  can  be 
easily  felt  through  the  mouth,  and  is  especially  dis- 
tinct when  that  bone  is  dislocated.  It  may  be 
noted  that  a  fair  space  exists  between  the  last 
molar  tooth  and  the  ramus  of  the  inferior  maxilla, 
through  which  a  patient  may  be  fed  by  a  tube  in 
cases  of  trismus  or  ankylosis  of  the  jaw. 

Congenital  dermoid  and  thyroid  cysts  are  some- 
times found  in  the  floor  of  the  mouth  between 
the  tongue  and  the  lower  jaw.  Such  cysts  are 
supposed  to  be  due  to  the  imperfect  closure  of 
the  first  visceral  or  postmandibular  cleft,  or 
to  an  aberrant  bud  of  the  median  thyroid 
diverticulum. 

The  gums  are  dense,  firm,  and  very  vascular. 
In  the  bleeding  that  follows  the  extraction  of 
teeth  much  of  the  blood  is  supplied  by  them.  The 
gums  are  particularly  affected  in  mercurial  poison- 


Vili]  THE    TONGtTE  147 

ing,  and  are  also  especially  involved  in  scurvy. 
In  chronic  lead-poisoning  a  blue  line  often  appears 
along  their  margins.  This  is  due  to  a  deposit  of 
lead  sulphide  in  the  gum  tissues,  which  is  thus  de- 
rived :  Food  debris  collected  about  the  teeth  in 
decomposing  produces  hydrogen  sulphide,  which, 
acting  upon  the  lead  circulating  in  the  blood,  pro- 
duces the  deposit.  The  blue  line,  therefore,  is  said 
not  to  occur  in  those  who  keep  the  teeth  clean. 

The  Tongue 

On  the  under  surface  of  the  tongue,  less  than 
\  an  inch  from  the  fraenum,  the  end  of  the  ranine 
vein  can  be  seen  beneath  the  mucous  membrane. 
Two  elevated  and  fringed  lines  of  mucous  mem- 
brane may  be  seen  on  the  under  surface  of  the 
organ  converging  towards  its  tip.  They  indicate 
the  position  of  the  ranine  artery,  which  is  more 
deeply  placed  than  the  vein,  close  to  which  it 
lies.  It  is  extremely  rare  for  the  tongue  to  be 
the  seat  of  congenital  defect.  The  tip  may 
be  irregularly  cleft  or  show  glandular  polypi, 
probably  derived  from  the  glands  normally  found 
beneath  the  tip  of  the  tongue.  Fournier  gives 
a  case  where  the  tongue  was  so  much  longer  than 
usual  that  the  chest  could  be  touched  with  its 
tip  while  the  head  was  held  erect. 

In  rare  cases  the  frseimm  linguae  may  be 
abnormally  short,  constituting  the  condition  known 
as  "  tongue-tie, "  which  is  really  a  very  uncommon 
affection.  The  genio-glossus,  the  chief  muscle  of 
the  tongue,  and  the  genio-hyoid  arise  from  the 
genial  tubercles  of  the  symphysis.  The  tongue  is 
kept  from  falling  backwards  by  its  attachments 
to  the  symphysis ;  if  these  attachments  were  cut, 
the  tongue  could  be  inverted  and  swallowed.  In 
Complete  anaesthesia,  as  in  that  produced  by 
chloroform,  when  all  the  muscular  attachments 
of  the  tongue  are  relaxed,  the  organ  is  apt  to 
fall  back  and  to  press  down  the  epiglottis,  so 
causing  suffocation. 


148  THE    HEAD    AND    NECK  [Chap. 

The  tongue  is  firm  and  dense,  but  contains, 
nevertheless,  a  sufficient  amount  of  connective 
tissue  to  cause  it  to  swell  greatly  when  inflamed. 
The  surface  epithelium  is  thick,  and  in  chronic 
superficial  inflammation  of  the  organ  it  often  be- 
comes heaped  up,  forming  dense  opaque  layers, 
ichthyosis  linguae,  plaques  des  fumeurs,  leucoma, 
etc.  From  the  mucous  glands,  situated  chiefly  be- 
neath the  mucous  membrane  near  the  base  of  the 
tongue,  the  mucous  cysts  are  developed  that  are 
sometimes  met  with  in  this  part. 

The  tongue  is  very  vascular,  and  is  in  conse- 
quence often  the  seat  of  naevoid  growths.  Its  main 
supply  is  from  the  lingual  artery.  This  vessel  ap- 
proaches the  organ  from  the  under  surface,  and  as 
cancer  usually  shows  a  tendency  to  spread  towards 
the  best  blood  supply,  it  is  to  be  noticed  that  car- 
cinoma of  the  tongue  nearly  always  tends  to  spread 
towards  the  deep  attachment  of  the  member.  At 
the  same  time  it  must  be  observed  that  the  main 
lymphatics  follow  the  same  course  as  the  main 
blood-vessels.  The  vascularity  of  the  tongue  is 
the  great  bar  to  its  easy  removal,  haemorrhage 
being  the  complication  most  to  be  dreaded  in  such 
operations. 

The  tongue  is  well  supplied  with  nerves,  that 
endue  it  not  only  with  the  special  sense  of  taste, 
but  also  with  common  sensation.  According  to 
Weber's  experiments,  tactile  sensibility  is  more 
acute  on  the  tip  of  the  tongue  than  it  is  on  any 
part  of  the  surface  of  the  body.  It  should  be  borne 
in  mind  that  the  lingual  nerve  supplies  the  fore 
part  and  sides  of  the  tongue  for  two-thirds  of  its 
surface,  while  the  glosso-pharyngeal  nerve  sup- 
plies the  mucous  membrane  at  its  base,  and  especi- 
ally the  papillae  vallatae.  In  painful  affections, 
situated  in  the  area  supplied  by  the  lingual  nerve, 
the  patient  is  often  troubled  with  severe  pains 
deep  in  the  region  of  the  meatus  of  the  ear,  and 
an  area  of  skin  from  the  ear  along  the  lower  bor- 
der of  the  jaw  may  be  tender  (Head).  i  The  anterior 
two-thirds  of  the  tongue  are  a  derivative  of  the  man- 


VIII] 


THE    TONGUE 


149 


dibular  arch,  which  also  forms  the  anterior  boun- 
dary of  the  meatus.  Hence  the  nerve  supply  of 
the  anterior  part  of  the  tongue  from  the  third  divi- 
sion of  the  fifth  nerve  and  the  reference  of  pain  to 
its  cutaneous  termination.  The  posterior  third  of 
the  tongue  is  derived  from  the  second  (hyoid)  and 
third  visceral  arches  and  is  associated  with  tender 
areas  in  the  skin  over  the  larynx  (Head).     Spas- 


Stylo-Hyoid 
Digastric 


Up.  deep  V 
Cerv.  Glands      V 


Fig.  34.— Lymphatics  of  the  tongue.     {After  Poirier.) 


modic  contraction  of  the  masticatory  muscles  is 
sometimes  found  to  accompany  painful  lingual  ul- 
cers when  involving  the  region  of  the  gustatory 
nerve.  There  would  seem  to  be  little  connexion 
between  an  abscess  over  the  occipital  region  and 
wasting  of  one  half  of  the  tongue.  But  Sir  James 
Paget  reports  the  following  case  : 

"  A  man  received  an  injury  to  the  back  of  his  head  that 
was  apparently  not  severe.  In  time  the  rigrht  half  of  the 
tongue  began  to  waste,  and  continued  to  waste  until  it  was 


150  THE    HEAD    AND    NECK  [Chap. 

less  than  half  the  size  of  the  unaltered  side.  An  abscess 
formed  over  the  occiput,  from  which  fragments  of  the  lower 
part  of  the  occipital  bone  were  removed.  After  the  removal 
of  all  the  dead  bone  the  tongue  began  to  recover,  and  in  one 
month  had  nearly  regained  its  normal  aspect." 

Here  the  atrophy  was  due  to  wasting  of  the  lin- 
gual muscles  produced  by  pressure  upon  the  hypo- 
glossal nerve,  which  leaves  the  skull  through  the 
anterior  condyloid  foramen  in  the  occipital  bone. 
The  case  illustrates  the  importance  of  remember- 
ing even  small  foramina,  and  the  structures  they 
transmit. 

The  tongue  contains  much  lymphoid  tissue,  a 
considerable  part  of  which  (the  lingual  tonsil)  is 
massed  under  the  mucous  membrane  at  the  pos- 
terior part  of  the  organ.  Hypertrophy  of  this  tissue 
may  lead  to  troublesome  symptoms  by  interference 
with  the  proper  action  of  the  epiglottis.  The  lin- 
gual and  pharyngeal  adenoid  tissue,  wTith  the  ton- 
sils proper,  form  a  complete  ring  of  lymphoid 
tissue  round  the  isthmus  of  the  fauces. 

The  lymphatics  of  the  tongue  are  large  and 
numerous,  and  offer  a  free  channel  for  the  dissem- 
ination of  cancerous  emboli.  They  are  arranged 
in  two  systems  :  (1)  Superficial,  forming  an  ex- 
tremely rich  plexus  in  the  submucous  tissue  on 
the  dorsum  and  sides  of  the  tongue ;  (2)  deep,  ar- 
ranged as  a  network  in  the  musculature  of  the 
tongue.  These  two  systems  are  in  free  communica- 
tion ;  Cheatle  found  that  the  genio-hyo-glossus 
muscle  was  a  common  site  of  secondary  deposit  in 
cases  of  cancer  of  the  tongue.  The  lymph  from 
these  two  systems  is  carried  off  by  the  following 
sets  of  efferent  vessels:  (1)  the  marginal  or  lateral 
vessels,  which  leave  the  submucous  plexus  on  the 
side  of  the  tongue  and  pass  partly  to  the  sub- 
maxillary group  of  glands  and  partly  to  the  upper 
deep  cervical  group  ;  (2)  the  central  vessels,  which 
form  between  the  two  genio-hyo-glossus  muscles 
and  end  in  the  upper  deep  cervical  glands;  (3)  the 
apical  vessels,  which  end  in  the  submental  gland 
and   in    the    upper    deep    cervical ;    (4)    the   basal 


VIIIJ         LYMPHATICS    OF    THE    TONGUE  151 

vessels  from  the  posterior  third  of  the  tongue 
which  terminate  in  the  upper  deep  cervical 
group. *  The  tongue  is  one  of  the  commonest 
sites  for  cancer,  and  the  disease  commonly  affects 
the  anterior  two-thirds,  which  are  derived  from 
the  mandibular  arch.  So  is  the  lower  lip,  which 
also  is  a  common  site.  Cancer  spreads  along 
the  lymphatic  vessels,  which  for  the  greater 
part  accompany  the  lingual  vein  and  artery.  The 
lymphatics  end  in  the  upper  deep  cervical  glands, 
behind  and  below  the  angle  of  the  jaw.  The 
main  vessels  become  blocked  by  the  invasion  of 
cancer  cells,  so  that  the  lymph  has  to  seek 
by-paths  and  circuitous  routes,  which  also  in 
time  become  occluded.  Thus  the  cancerous  in- 
vasion may  become  widely  spread  and  in  many 
directions.  The  lymphatic  glands  over  the  sub- 
maxillary gland,  the  lymphoid  tissue  in  that 
gland  and  in  the  sublingual,  become  the  seats 
of  secondary  deposit.  The  submental  gland  may 
also  be   affected. 

In  the  strange  congenital  affection  known  as 
macroglossia  the  tongue  becomes  much  enlarged, 
and  in  some  cases  may  attain  prodigious  dimen- 
sions. The  enlargement  is  primarily  due  to  the 
greatly  dilated  condition  of  the  lymphatic  chan- 
nels of  the  organ  (hence  the  name,  lymphangioma 
cavernosum,  proposed  by  Yirchow),  and  to  an  in- 
creased development  of  lymph  tissue  throughout 
the  part.  The  portion  most  conspicuously  affected 
is  the  base  of  the  tongue,  where  the  lymphatics 
are  usually  the  most  numerous. 

Accessory  glands  about  the  tongue.— 
Streckeisen  states  that  accessory  glands,  belong- 
ing to  the  thyroid  body,  are  frequently  found  in 
the  vicinity  of  the  hyoid  bone.  They  are  also 
found  in  the  basal  part  of  the  tongue,  near  the 
foramen  caecum  (Makins).  Some  may  be  super- 
ficial to  the  mylohyoid  muscle,  others  may  be  just 

*  For  a  full  account  of  the  lymphatics  see  Poirier's  "Lymphatics." 
translated  by  Cecil  Leaf,  19Q3. 


152  THE    HEAD    AND    NECK  [Chap. 

above  the  hyoid  bone,  and  others  in  the  hollow  of 
that  bone.  Cysts  lined  with  ciliated  epithelium 
may  sometimes  be  found  in  the  same  situations. 
All  these  structures  are  the  remains  of  the 
neck  of  the  central  diverticulum  which  is  pro- 
truded from  the  ventral  wall  of  the  pharynx  in 
the  embryo,  and_  from  which  the  isthmus  and 
adjoining  part  of  the  thyroid  gland  are  formed. 
The  foramen  ccecum  on  the  tongue  indicates 
the  spot  where  this  diverticulum  arises  from 
the  pharynx.  Ducts  lined  with  epithelium  have 
been  found  leading  from  the  foramen  caecum  to 
accessory  glands  about  the  hyoid  bone.  It  is 
probably  from  these  glandular  and  epithelial 
collections  about  the  hyoid  bone  that  certain 
deep-seated  forms  of  cancer  of  the  neck  are  de- 
veloped. Some  of  these  take  the  form  of  malig- 
nant cysts  described  by  the  author  (Path.  Soc. 
Trans.,  1886). 

Excision.— Many  different  methods  have  been 
adopted  for  the  removal  of  the  entire  tongue.  It 
has  been  removed  through  the  mouth  by  the  ecra- 
seur  or  the  scissors,  the  latter  operation  being  per- 
formed with  or  without  previous  ligature  of  the 
lingual  arteries  in  the  neck.  It  is  difficult,  however, 
fully  to  expose  the  deeper  attachments  of  the  organ 
through  the  comparatively  small  orifice  of  the 
mouth.  To  obtain  more  room  the  cheek  has  been 
slit  up  in  one  procedure,  while  the  lower  lip  and 
symphysis  of  the  lower  jaw  have  been  divided  in 
another. 

In  another  series  of  operations  the  tongue  has 
been  reached,  or  the  organ  has  been  fully  exposed, 
bv  an  incision  made  between  the  hyoid  bone  and 
the  inferior  maxilla.  More  recently  Kocher  has 
exposed  the  tongue  from  the  neck,  and  has  reached 
it  by  an  incision  commencing  near  the  ear  and  fol- 
lowing the  anterior  border  of  the  sterno-mastoid 
muscle  as  far  as  the  hyoid  bone,  whence  it  turns 
upwards  along  the  anterior  belly  of  the  digastric 
muscle.  This  method  allows  free  removal  of  the 
upper  deep  cervical  glands,  the  lymphatic  glands, 


Villi  THE    PALATE  153 

and  the  tissue  over  and  in  the  submaxillary  and 
sublingual  glands  which  form  the  seats  of  second 
ary  cancerous  deposits,   besides  giving  an  oppor- 
tunity  of  completely  controlling  haemorrhage   by 
a  preliminary  ligature  of  the  lingual  artery. 

In  the  removal  of  the  entire  organ,  the  follow- 
ing parts  are  of  necessity  divided :  The  frsenum, 
the  mucous  membrane  along  the  sides  of  the 
tongue,  the  glosso-epiglottic  folds,  the  genio-hyo- 
glossus,  hyo-glossus,  stylo-glossus,  palato-glossus 
muscles,  the  few  fibres  of  the  superior  and  inferior 
linguales  muscles  that  are  attached  to  the  hyoid 
bone,  the  terminal  branches  of  the  gustatory, 
glosso-pharyngeal,  and  hypoglossal  nerves,  the 
lingual  vessels,  and,  at  the  side  of  the  tongue  near 
its  base,  some  branches  of  the  ascending  pharyn 
geal  artery,  and  of  the  tonsillar  branch  of  the 
facial  artery. 

When  both  Unguals  have  been  ligatured  in  the 
neck  (through  the  hyo-glossus  muscle)  before  re- 
moving the  tongue,  bleeding  still  takes  place  from 
the  dorsalis  linguae  branches  of  the  lingual  and 
from  small  branches  of  the  ascending  pharyngeal 
and  facial  arteries. 

The  Palate 

The  arch  of  the  hard  palate  varies  in  height 
and  shape  in  different  individuals,  and  it  has 
been  said  that  the  arch  is  particularly  narrow 
and  high  in  congenital  idiots.  The  outline  of 
this  arch  is  of  some  moment  in  operations  upon 
the  palate. 

Cleft  palate.  —  In  order  to  understand  the 
various  forms  of  cleft  which  occur  in  the  palate 
and  upper  lip,  it  is  necessary  to  review  briefly  the 
development  of  these  parts  ;  for  all  forms  of  cleft 
palate  and  "  hare-lip  "  are  due  to  an  incomplete 
fusion  of  parts.  In  Fig.  35,  A,  the  bony  palate  at 
birth  is  shown  to  be  made  up  of  three  elements  :  (1) 
the  premaxillary,  carrying  the  four  incisor  teeth ; 
(2)   the   right  maxillary;    (3)   the   left  maxillary, 


154 


THE    HEAD    AND    NECK 


[Chap. 


bearing  the  right  and  left  canines  and  milk  molars. 
These  three  parts  are  different  in  origin  :  the  pre- 
maxillary  part  is  developed  in  the  mesial  nasal 
process  (Fig.  27,  p.  119)  ;  the  maxillary  parts  from 
the  right  and  left  maxillary  processes.  Fusion 
of  the  various  elements  to  form  the  palate  cont- 
inences anteriorly  and  proceeds  backwards.  In 
the  posterior  two-thirds  of  the  palate  the  maxillary 
processes  fuse  with  each  other  in  the  median  line, 
but  in  the  anterior  third  they  unite  with  the  pre- 


Fig.  35. — Illustrating  the  relationship  of  the  lateral  incisor 
tooth  to  the  palatal  cleft. 

A,  Normal  hard  palate.    The  premaxilla  is  stippled  ;  the  lateral 
incisor  occurs  in  the  suture  hetween  it  and  the  maxilla. 

B,  Double  cleft  of  palate,  the  lateral  incisor  being  situated  on  the 

premaxilla  to  the  inner  side  of  the  cleft.    The  septum  of  the  nose 
is  exposed  in  the  cleft  between  the  maxillary  bones. 

C,  Double  cleft  palate,  the  lateral  incisor  being  situated  on  the 

maxilla  to  the  outer  side  of  the  cleft. 


maxillary  part.  Thus  the  line  of  fusion  is 
Y-shaped,  the  premaxillary  part  occupying  the 
fork.  In  the  majority  of  cases  the  cleft  occurs  in 
the  position  of  the  main  stem  of  the  Y,  or  it  may 
affect  only  the  soft  palate ;  or  it  may  extend 
forwards  to  the  alveolus  on  one  side  or  on  both,  as 
is  shown  in  Fig.  35,  b,  c.  The  lateral  incisor  is 
developed  in  the  groove  between  the  premaxillary 
and  maxillary  elements ;  if  the  condition  of  cleft 
palate  occurs,  the  developmental  elements  separate 
as  growth  proceeds ;  the  bud  of  the  lateral  incisor 
may  adhere  to  either  side  of  the  cleft  thus  formed ; 


VIIIj  #AftD    PALATE  155 

hence  in  some  cases  this  incisor  is  found  on  the 
premaxillary  process;  in  others,  in  the  maxillary 
(see  Fig.  35,  b,  c).  Each  premaxilla  may  show 
two  centres  of  ossification,  but  the  cleft  is  not,  as 
is  so  often  said,  the  result  of  the  failure  of  union 
of  two  centres  of  ossification,  but  is  due  to  the 
separation  of  the  developmental  parts  of  the 
palate.  As  growth  goes  on,  the  cleft  becomes 
wider. 

The  upper  lip  is  developed  from  the  same  three 
elements  as  the  palate  (Fig.  27,  p.  119);  if  the 
palatal  cleft  extends  to  the  alveolus  the  lip  is  also 
affected,  but  a  cleft  on  one  or  both  sides  of  the 
lip  may  occur  without  a  cleft  of  the  palate.  The 
premaxillary  or  median  element  of  the  lip  is  also 
bilateral,  but  it  is  extremely  rare  to  find  a  per- 
sistent separation  of  its  two  parts.  In  cases  of 
double  hare-lip  one  sees  occasionally  two  papillse 
on  the  lower  lip,  fitting  into  the  clefts  in  the  upper 
when  the  lips  are  in  apposition. 

The  mucous  membrane  covering  the  hard 
palate  is  peculiar  in  that  it  is  practically  one 
with  the  periosteum  covering  the  bones;  and, 
therefore,  in  dissecting  up  this  membrane  the  bone 
is  bared,  as  the  mucous  membrane  and  the  perios- 
teum cannot  be  separated.  The  membrane  is  thin 
in  the  middle  line,  but  is  much  thicker  at  the  sides 
near  the  alveoli,  the  increased  thickness  depend- 
ing mainly  upon  the  introduction  of  a  number 
of  mucous  glands  beneath  the  surface  layers,  such 
glands  being  absent  in  the  middle  line.  The 
density  and  toughness  of  the  soft  covering  of  the 
hard  palate  render  it  very  easy  to  manipulate 
when  dissected  up  in  the  form  of  flaps,  as  in  the 
operation  for  cleft  palate. 

Mr.  Godlee  has  described  a  number  of  cases 
in  which  a  bony  elevation — the  torus  palatinus — 
is  found  on  the  posterior  part  of  the  under- 
surface^  of  the  hard  palate.  The  elevation  or 
exostosis  is  commoner  in  lower  races  than  in 
Europeans,  and  begins  to  form  as  adult  life  is 
reached.     It  is  due  to  a  heaping-up  of  bone  on 


156  THE    HEAD    AND    NECK  [Chap 

each  side  of  the  median  suture  of  the  palate, 
and   never   attains   a  large  size. 

The  main  blood  supply  of  the  bones  of  the 
hard  palate  and  of  its  mucous  covering  is  derived 
from  the  descending  palatine  branch  of  the  in- 
ternal maxillary  artery.  This  vessel,  which  is 
practically  the  only  vessel  of  the  hard  palate, 
emerges  from  the  posterior  palatine  canal  near 
the  junction  of  the  hard  palate  with  the  soft,  and 
close  to  the  inner  side  of  the  last  molar  tooth. 
The  vessel  runs  forwards  and  inwards,  to  end 
at  the  anterior  palatine  canal.  Its  pulsations  on 
the  palate  can  often  be  distinctly  felt.  In  dis- 
secting up  muco-periosteal  flaps  from  the  hard 
palate,  it  is  most  important  to  make  the  incision 
in  the  mucous  membrane  close  to,  and  parallel 
with,  the  alveolus,  so  that  this  artery  may  be  in- 
cluded in  the  flap  and  its  vitality  therefore  not 
be  endangered.  By  such  an  incision,  also,  un- 
necessary bleeding  is  avoided.  In  dissecting  up 
the  flap  it  should  be  remembered  that  the  artery 
runs  much  nearer  to  the  bone  than  to  the  mucous 
surface. 

The  soft  palate  is  of  uniform  thickness,  its 
average  measurement  being  estimated  at  about  \ 
of  an  inch,  When  the  soft  palate  is  cleft,  the 
edges  of  the  fissure  are  approximated  during 
swallowing  by  the  uppermost  fibres  of  the  superior 
constrictor.  This  approximation  may  narrow  the 
cleft  to  one-third  or  one-half  of  its  previous  size. 
The  muscles  that  tend  to  widen  the  cleft  are,  in 
the  main,  the  levator  palati  and  tensor  palati. 
It  is  necessary  that  these  muscles  should  be 
divided  before  attempting  to  close  the  cleft  by 
operation.  The  levator  palati  crosses  the  palate 
obliquely  from  above  downwards  and  inwards  on 
its  way  to  the  middle  line,  lying  nearer  to  the 
posterior  than  the  anterior  surface  of  the  velum. 
The  tensor  palati  turns  round  the  hamular  pro- 
cess, and  passes  to  the  middle  line  in  a  nearly 
horizontal  direction  (Fig.  36).  The  hamular  pro- 
cess can  be  felt  through  the  soft  palate  just  behind 


vnn 


SOFT    PALATE 


157 


.:.:>&*£  S'.^^P^^A^tC^' 


and  to  the  inner  side  of  the  last  upper  molar 
tooth.  There  are  three  principal  methods  of 
dividing  these  muscles  :  (1)  Fergusson's  :  A  small 
knife,  with  the  blade  at  right  angles  to  the  stem, 
is  passed  through  the  cleft,  and  is  made  to  divide 
the  levator  palati  by  an  incision  on  the  posterior 
aspect  of  the  palate,  trans- 
verse to  the  direction  of  the 
muscle.  The  tensor  is  not 
divided  in  this  procedure. 
(2)  Pollock's  :  A  thin  narrow 
knife,  with  the  cutting  edge 
upwards,  is  introduced  into 
the  isoft  palate  a  little  in 
front,  and  to  the  inner  side, 
of  the  hamular  process.  The 
tendon  of  the  tensor  muscle 
is  above  the  knife,  and  is 
cut  as  the  knife  is  pushed 
upwards  and  inwards.  The  _.  _  ._ 
knife  is  inserted  until  its  Fl&:  36  -Muscles  of 
point  presents  at  the  upper  ^ .8°.ft  palate'  from 
part   of   the   cleft.      As   it   is       beh,nd- 

bi»incr    wi+hrlrnwn      if    i«   mnHp    rt'  Levator  palati  ;  6,  tensor 
bting   Wltnarawn,    It   IS  made  palati  ;c,  hamular  pro- 

to  cut  the  posterior  surtace  cess ;  d,  wall  of  pha- 
of  the  velum  to  a  sufficient 
depth  to  divide  the  leva- 
tor palati  (Fig.  36).  (3) 
Bryant's  :  Here  the  palate 
muscles  are  divided  by  a 
cut  with  the  scissors  that 
involves  the  entire  thickness  of  the  velum,  the 
cut  being  at  the  side  of  the  velum,  and  nearly 
parallel  to  the  cleft. 

The  blood  supply  of  the  soft  palate  is  derived 
from  the  descending  palatine  branch  of  the  in- 
ternal maxillary  artery,  the  ascending  pharyn- 
geal artery,  and  the  ascending  palatine  branch 
of  the  facial  artery.  The  latter  vessel  reaches  the 
velum  by  following  the  levator  palati  muscle,  and 
must  be  divided  in  the  section  made  of  this  muscle 
in  the  procedures  just  described. 


rynx  ;  e,  azygos  uvulae  ; 
f,  the  point  of  entry  of 
the  knife  in  Pollock's 
operation  ;  above  it  is 
the  line  of  incision 
made  on  withdrawing 
the  knife. 


158  THE    HEAD    AND    NECK  [Chap. 

The  muscles  of  the  palate  are  supplied  by 
several  nerves.  The  levator  palati,  azygos  uvulae, 
and  palato-pharyngeus  are  inneryated  with  the 
muscles  of  the  pharynx  by  the  spinal  accessory ; 
the  palato-glossus  with  the  muscles  of  the  tongue 
from  the  hypo-glossal,  and  the  tensor  palati  with 
the  tensor  tympani  from  the  third  division  of  the 
fifth  nerve  through  the  otic  ganglion. 

The  Pharynx 

The  pharynx  is  about  5  inches  in  length. 
It  is  much  wider  from  side  to  side  than  from 
before  backwards.  It  is  widest  at  the  level  of  the 
tip  of  the  greater  cornua  of  the  hyoid  bone,  where 
it  measures  about  2  inches.  It  is  narrowest  where 
it  joins  the  gullet  opposite  the  cricoid  cartilage, 
its  diameter  here  being  less  than  }  of  an  inch. 
The  pharynx  is  not  so  large  a  space  as  supposed, 
for  it  must  be  remembered  that  during  life  it  is 
viewed  very  obliquely,  and  erroneous  notions  are 
thus  formed  of  its  antero-posterior  dimensions. 
The  distance  from  the  arch  of  the  teeth  to  the 
commencement  of  the  gullet  is  about  6  to  7  inches, 
a  measurement  that  should  be  borne  in  mind 
in  extracting  foreign  bodies.  Foreign  bodies 
passed  into  the  pharynx  are  most  apt  to  lodge 
at  the  level  of  the  cricoid  cartilage,  a  point  that, 
in  the  adult,  is  a  little  beyond  the  reach  of  the 
finger.  The  history  of  foreign  bodies  in  the 
pharynx  shows  that  that  cavity  is  very  dilatable, 
and  can  accommodate  for  some  time  large  sub- 
stances. Thus,  in  a  case  reported  by  Dr.  Geoghc- 
gan,  a  man  of  60,  who  had  had  for  months  some 
trouble  in  his  throat  for  which  he  could  not 
account,  was  supposed  to  have  cancer.  On  ex- 
amination, however,  a  plate  carrying  five  false 
teeth,  and  presenting  niches  for  five  natural  ones, 
was  found  embedded  in  the  pharynx,  where  it 
had  been  lodged  for  five  months.  The  plate  had 
been  swallowed  during  sleep  {Med.  Press,  1866). 
In  the  Lancet  for  1868  is  an  account  of  a  mutton 
chop    that   became   lodged    in   the    pharynx   of   a 


VIII]  THE    PHARYNX  159 

gluttonous  individual.  The  chop  presented  the 
ordinary  vertebral  segment  of  bone,  together  with 
lj  inches  of  rib,  and  was  "  pretty  well  covered 
with  meat."  Attempts  to  remove  it  failed,  and 
it  was  finally  vomited  up.  Dr.  Hicks  (Lancet, 
1884)  reports  the  case  of  a  woman  who  committed 
suicide  by  cramming  half  a  square  yard  of  coarse 
calico  (belonging  to  her  nightdress)  into  her 
mouth  and  throat. 

The  walls  of  the  pharynx  are  in  relation  with 
the  base  of  the  skull,  and  with  the  upper  six  cer- 
vical vertebrae.  The  arch  of  the  atlas  is  almost 
exactly  on  a  line  with  the  hard  palate.  The  axis 
is  on  a  line  with  the  free  edge  of  the  upper  teeth. 
The  termination  of  the  pharynx  corresponds  to 
the  sixth  cervical  vertebra.  The  upper  vertebrae 
can  be  examined,  as  regards  their  anterior  sur: 
face,  from  the  mouth.  When  the  bones  about  the 
pharynx  are  diseased,  the  necrosed  parts  may  be 
discharged  by  that  cavity.  Thus  portions  of  the 
atlas  and  axis  have  been  expelled  by  the  mouth, 
as  also  have  been  some  fragments  of  comparatively 
large  size  thrown  off  by  the  occipital  and  sphenoid 
bones. 

The  mucous  membrane  of  the  pharynx  is  vas- 
cular, and  readily  inflamed;  and  such  inflamma- 
tions are  peculiarly  dangerous,  in  that  they  may 
spread  to  the  lining  membrane  of  the  larynx. 
The  submucous  tissue  of^  the  aryteno-epiglottic 
folds  and  of  the  neighbouring  part  of  the  pharynx 
is  peculiarly  loose,  and  in  cedematous  conditions 
the  upper  aperture  of  the  larynx  may  be  almost 
closed. 

Much  adenoid  tissue  is  distributed  in  the 
mucous  membrane  of  the  pharynx,  and  it  is  this 
tissue  that  is  the  primary  seat  of  inflammation 
in  scrofulous  pharyngitis.  A  distinct  collection 
of  adenoid  tissue — the  naso-pharyngeal  tonsil — 
is  found  in  the  roof  of  the  naso-pharynx  (see. 
Figs.  37  and  25).  It  is  embedded  in  the  thick 
mucous  membrane,  and  extends  from  the  base  of 
the  septum  of  the  nose  to  the  mid-point  of  the 


160 


THE    HEAD   AND    NECK 


[Chap. 


Roof  of 
Naso-Pharynx 

Pharyng    Tonsil 

Opening  of 
Eustach    Tube 

Soft  Palate 


basilar  process  of  the  skull.  The  centre  of  the  ton- 
sil is  marked  by  a  fissure  or  depression  bounded 
on  each  side  by  two  or  three  folds  of  mucous 
membrane  laden  with  adenoid  tissue.  It  reaches 
its  maximum  size  about  the  tenth  year.  It  ex- 
tends laterally  towards  the  recesses  behind  the 
Eustachian  tubes,  and  may  invade  these  recesses 
and  thus  prevent  the  free  opening  of  the  tubes. 
This  deposit  of  adenoid  tissue  may  undergo 
hypertrophic  change,  and  the  condition  known  as 
"adenoid  vegetations"  or  "post-nasal  growths" 
be  produced.    These  growths  may  cause  deafness  and 

may  block  the  pos- 
terior nares.  They 
need  to  be  removed 
by  operation. 

The  tissue  imme- 
diately outside  the 
pharyngeal  walls  is 
lax,  and  favours 
the  spread  of  effu- 
sion. Thus,  in  acute 
inflammation  of  the 
pharynx  the  effusion 
Fig.  37. -Tonsil  of  the  nasopharynx  has  been  found  to 
of  a  boy  aged  2  years.  extend      along      the 

( From  a  preparation  made  by  Professor  oesophagus,       reach- 
Symington.)  mg     the     posterior 

mediastinum,  and 
advancing  even  to  the  diaphragm.  In  the  lax 
connective  tissue  between  the  pharynx  and  the 
spine  abscess  is  not  infrequent,  due,  as  a  rule,  to 
caries  of  the  vertebrae  (postpharyngeal  abscess). 
In  this  connective  tissue,  and  opposite  the  axis, 
is  also  found  a  lymphatic  gland  that  receives 
lymphatics  from  the  nasal  cavity  and  naso- 
pharynx. This  gland  may  prove  the  seat  of  a 
suppuration.  Such  collections  may  so  push  tor- 
ward  the  posterior  pharyngeal  wall  as  to  depress 
the  soft  palate,  or  may  cause  severe  dyspnoea 
by  interference  with  the  larynx.  The  matter  may 
discharge  itself  through  the  mouth,  or  may  reach 


Post.  Border  of 
Septum  Nasi 


VIII]  THE    TONSIL  161 

the  neck  by  passing  behind  the  great  vessels  and 
the  parotid  gland,  presenting  ultimately  beneath 
or  at  one  border  of  the  sterno-mastoid  muscle. 

Many  structures  of  importance  are  in  relation 
with  the  lateral  walls  of  the  pharynx,  the  prin- 
cipal being  the  internal  carotid  artery,  the  vagus, 
glossopharyngeal,  and  hypoglossal  nerves  (Fig. 
31,  p.  128).  The  internal  carotid  is  so  close  to 
the  pharynx  that  its  pulsations  may  be  felt  by 
the  finger  introduced  through  the  mouth.  These, 
and  other  deep  structures  in  the  neck,  may  be 
wounded  by  foreign  bodies  that,  passing  in  at 
the  mouth,  have  been  thrust  through  the  pharynx 
into  the  cervical  tissues.  The  internal  jugular 
vein  is  at  some  distance  from  the  pharynx,  especi- 
ally at  its  upper  part  (Fig.  31,  p.  128).  The 
styloid  process,  when  prominent,  and  an  ossified 
stylo-hyoid  ligament,  can  also  be  felt  at  the  side 
of  the  pharynx  immediately  behind  the  tonsil. 
In  more  than  one  case  an  ossified  stylo-hyoid 
ligament  has  been  mistaken  for  a  foreign  body, 
and  an  attempt  made  to  excise  it. 

The  tonsil  is  lodged  between  the  anterior 
and  posterior  palatine  arches.  It  is  in  relation 
externally  with  the  superior  constrictor  muscle 
(Fig.  31,  p.  128),  and  corresponds,  as  regarls 
the  surface,  to  the  angle  of  the  lower  jaw. 
When  hypertrophied,  the  mass  tends  to  develop 
towards  the  middle  line,  where  no  resistance  is 
encountered,  and  to  effect  but  little  change  in 
its  external  relations.  The  mass,  often  mistaken 
for  the  enlarged  tonsil  in  the  neck,  is  formed 
of  enlarged  glands,  situate  near  the  tip  of  the 
great  cornu  of  the  hyoid  bone,  and  overlying 
the  internal  jugular  vein.  These  glands  receive 
the  tonsillar  lymphatics,  and  are  almost  invari- 
ably enlarged  in  all  tonsil  affections.  The  fact 
that  these  glands  are  so  frequently  the  first  to  en- 
large when  the  cervical  glands  become  tubercular 
points  to  the  tonsil  as  a  common  site  of  primary 
infection.  The  tonsil  is  closely  enough  attached  to 
the  pharyngeal  wall  to  be  affected  by  the  movements 


162 


THE    HEAD    AND    NECK 


[Chap. 


of  the  pharyngeal  muscles.  Thus  it  is  moved  in- 
wards by  the  superior  constrictor  muscle  during 
the  act  of  swallowing,  and  may  be  drawn  out- 
wards, on  the  other  hand,  by  the  stylo-pharyngeus 
muscle.  The  ease  with  which  a  tonsil  can  be 
reached  depends,  other  things  being  equal,  upon 
the  extent  to  which  it  can  be  withdrawn  by  the 
stylo-pharyngeus,  and  upon  the  development  of 
the  anterior  palatine  arch,  which,  to  some  extent, 
hides  the  tonsil.     A  child  with  a  prominent  an- 


Hard  Palate     2 


Soft  Palate 

Plica  Semilunaris 

Post.   Pillar 
Tonsil 
Plica  Triangularis 


Fig.  38. — Diagram  of  the  pillars  of  the  fauces  and  of  the 
tonsil. 

terior  palatine  arch,  containing  a  well-developed 
palato-glossus  muscle,  and  with  a  vigorous  stylo- 
pharyngeus,  can  for  a  long  time  elude  the  tonsil 
guillotine. 

The  tonsil  is  variable  in  shape ;  it  is  frequently 
divided  into  three  masses,  and,  besides  numerous 
crypts,  shows  towards  its  upper  part,  where  the 
anterior  and  posterior  pillars  meet  with  the  soft 
palate,  a  deep  recess  or  pocket — the  tonsillar 
recess.  This  recess  is  the  remnant  of  the  first 
visceral  cleft  in  which  the  tonsil  was  developed 
(Seccombe    Hett).      From    the    anterior    pillar    a 


VIII]  THE    TONSIL  163 

sharp  fold  of  mucous  membrane  passes  back- 
wards, to  end  on  the  tonsil — the  plica  triangularis 
(sec  Fig.  38) — while  another  fold  may  join  the 
pillars  over  the  tonsillar  recess  {plica  semilunaris) . 
The  tonsil  is  separated  from  the  superior  con- 
strictor by  a  fine  fibrous  capsule ;  its  lymphatics 
perforate  the  constrictor  Two  chief  forms  of 
tonsil  may  be  recognized  :  the  embedded,  where 
the  adenoid  tissue  increases  beneath  the  level 
of  the  pillars ;  and  the  projecting,  where  the 
increase  affects  chiefly  the  exposed  part  of  the 
tonsil   (S.   Hett). 

Deafness  is  often  complained  of  when  the  tonsil 
is  hypertrophied.  This  is  not  due  to  closure  of 
the  Eustachian  tube  by  the  direct  pressure  of  the 
enlarged  mass.  Such  pressure  is  anatomically  im- 
possible. The  large  tonsil  may,  however,  affect 
the  patency  of  the  tube,  by  disturbing  the  soft 
palate,  and  through  it  the  tensor  palati  muscle, 
which  is  much  concerned  in  keeping  open  the 
Eustachian  tube.  The  deafness  in  these  cases  is 
probably  due  rather  to  an  extension  of  the  hyper- 
trophic process  to  the  lining  membrane  of  the 
tube  than  to  any  pressure  effects,  since  it  is 
usually  not  improved  until  some  time  after  the 
tonsil  has  been  removed.  The  tonsil  tissue  is  for 
the  most  part  collected  around  a  number  of 
crypts.  The  decomposition  of  retained  epithelial 
structures  within  these  recesses  produces  the  fetid 
breath  often  noticed  in  cases  of  enlarged  tonsil, 
and  probably  incites  the  attacks  of  inflammation 
to  which  such  tonsils  are  liable,  Calculi  may 
form  in  these  crypts  and  give  rise  to  a  spasmodic 
cough.  In  this  case  the  glosso-pharyngeal  nerve 
conveys  the  afferent  impulse  to  the  respiratory 
centre. 

The  tonsil  is  very  vascular,  receiving  blood 
from  the  tonsillar  and  palatine  branches  of  the 
facial  artery,  from  the  descending  palatine  branch 
of  the  internal  maxillary,  from  the  dorsalis  lin- 
guae of  the  lingual,  and  from  the  ascending 
pharyngeal.     Hence    the    operation    of    removing 


164  THE    HEAD    AND    NECK        [Chap.VlIl 

the  tonsil  is  often  associated  with  free  bleeding. 
The  internal  carotid  artery  is  close  to  the 
pharynx,  but  some  way  behind  the  gland  (Fig.  31, 
p.  128).  The  vessel  is,  indeed,  about  f  of  an  inch 
posterior  to  that  body,  and  is  in  comparatively 
little  danger  of  being  wounded  when  the  tonsil 
is  excised.  The  internal  jugular  vein  is  a  con- 
siderable distance  from  the  tonsil.  The  facial 
artery,  in  its  cervical  stage,  is  close  to  the  tonsil. 
Of  important  cervical  structures,  the  nearest  to 
the  tonsil  is  the  glosso-pharyngeal  nerve.  The 
ascending  pharyngeal  artery  is  also  in  close  re- 
lation with  it.  Although  this  vessel  is  of  small 
size,  bleeding  from  it  has  proved  fatal,  as  the 
following  interesting  case,  reported  by  Mr.  Mor- 
rant  Baker,    will   show  : 

A  man,  aged  23,  fell  when  drunk,  and  grazed  his  throat 
with  the  end  of  a  tobacco-pipe  he  was  smoking  at  the  time. 
He  thought  nothing  of  the  accident.  In  two  days  he  came 
to  the  hospital  with  what  appeared  to  be  an  acutely  inflamed 
tonsil.  The  tonsil  was  punctured,  but  nothing  escaped  save 
a  little  blood.  Several  haemorrhages  occurred  from  the  tonsil 
wound,  and  on  the  fourth  day  after  the  accident  1  inch  of 
the  stem  of  a  clay  pipe  was  discovered  deeply  embedded  in 
the  glandular  substance.  It  was  removed,  and  the  common 
carotid  tied.  The  patient,  however,  never  rallied  from  the 
previous  severe  haemorrhages,  and  soon  died.  The  autopsy 
showed  that  the  stem  of  the  pipe,  which  had  not  been  missed 
by  the  patient,  had  divided  the  ascending  pharyngeal  artery 
(St.  Bart:s  Hasp.  Rejwrts,  1876). 

The  tonsil  is  often  the  seat  of  malignant 
growths.  Such  tumours  have  been  removed 
through  the  mouth,  but  are  more  conveniently 
dealt  with  through  an  incision  in  the  neck  along 
the  anterior  edge  of  the  sterno-mastoid  (Cheever's 
operation). 


CHAPTER    IX 

THE   NECK 

Surface    anatomy;    bony   points,— The    hyoid 
bone  is  on  a  level  with  the  fourth  cervical  vertebra, 
while  the  cricoid  cartilage  is  opposite  the  sixth. 
The  upper  margin  of  the  sternum  is  on  a  level 
with    the    disc    between    the    second    and    third 
dorsal  vertebrae.     (See  p.  180.)    At  the  back  oi  the 
neck  there  is  a  slight  depression   in  the  middle 
line  which  descends  from  the  occipital  protuber- 
ance, and  lies  between  the  prominences  formed  by 
the  trapezius  and  complexus  muscles  of  the  two 
sides.     At  the  upper  part  of  this  depression  the 
spine  of  the  axis  can  be  made  out  on  deep  pres- 
sure.    Below  this,  the  bony  ridge  formed  by  the 
spines  of  the  third,  fourth,  fifth,  and  sixth  cervi- 
cal vertebrae  can  be  felt,  but  the  individual  spines 
cannot  usually  be  distinguished.     At  the  root  of 
the    neck    the    spinous    process    of    the    vertebra 
prominens    is    generally    very    obvious.      The    trans- 
verse  process    of   the   atlas   may   be   felt  just   below 
and  in   front  of  the  tip  of  the  mastoid  process. 
By  deep  pressure  in  the  upper  part  of  the  supra^ 
clavicular    fossa,    the    transverse    process    of    the 
seventh    cervical    vertebra   can    be    distinguished. 
If  pressure  be  made  over  the  line  of  the  carotid 
vessels    at    the    level    of    the    cricoid    cartilage, 
the    prominent    anterior    tubercle    of    the    trans- 
verse    process    of     the     sixth    cervical     vertebra 
can  be  felt.     This  is  known  as  the  "  carotid  tuber- 
cle.^    The    carotid    artery    lies    directly    over    it, 
165 


166  THE    HEAD    AND    NECK  '    [Chap. 

and  in  ligaturing  that  vessel  some  surgeons  make 
important  use  of  this  tubercle  as  a  landmark.  If 
a  horizontal  section  of  the  neck,  in  a  muscular 
subject,  taken  about  the  level  of  the  sixth  cervical 
vertebra,  be  viewed,  the  whole  of  the  body  of  the 
vertebra  divided  will  be  seen  to  lie  within  the 
anterior  half  of  the  section. 

Middle  line. — In  the  receding  angle  below 
the  chin  the  hyoid  bone  can  be  felt  and  its 
body  and  greater  cornua  well  made  out.  About 
a  finger's-breadth  below  it  is  the  thyroid  cartilage. 
The  details  of  this  latter  are  readily  distin- 
guished, and  below  it  the  cricoid  cartilage,  crico- 
thyroid space,  and  trachea  can  be  easily  recog- 
nized. The  separate  rings  of  the  trachea  cannot 
be  felt.  The  trachea  is  less  easily  made  out  as  it 
passes  down  the  neck.  As  it  descends  it  takes  a 
deeper  position,  and  at  the  upper  border  of  the 
sternum  lies  nearly  \\  inches  from  the  surface. 

The  rima  glottidis  corresponds  to  the  middle 
of  the  anterior  margin  of  the  thyroid  cartilage. 

Unless  enlarged,  the  thyroid  gland  cannot 
be  made  out  with  certainty.  According  to  Mr. 
Holden,  the  pulse  of  the  superior  thyroid  artery 
can  be  felt  at  its  upper  and  anterior  part. 

The  anterior  jugular  veins  descend  on  either 
side  of  the  middle  line  upon  the  sterno-hyoid  mus- 
cles. They  commence  in  the  submaxillary  region, 
pierce  the  fascia  just  above  the  inner  end  of  the 
clavicle,  and,  passing  beneath  the  origin  of  the 
sterno-mastoid  muscle,  end  in  the  external  jugu- 
lar. The  inferior  thyroid  veins  lie  in  front  of 
the  trachea,  below  the  isthmus. 

Side  of  the  neck.  Muscles. — The  sterno- 
mastoid  muscle,  especially  in  thin  subjects  and 
when  thrown  into  action,  is  a  prominent  feature 
in  the  neck.  The  anterior  border  of  the  muscle  is 
very  distinct.  The  posterior  border  is  less  promi- 
nent, especially  at  its  upper  part.  A  communi- 
cating branch  from  the  facial  vein  generally  runs 
along  the  anterior  border  of  the  muscle  to  meet 
the   anterior  jugular  vein   at  the  lower   part  of 


IXJ  VESSELS    OF    THE    NECK  167 

the  neck.  The  interval  between  the  sternal  and 
clavicular  parts  of  the  muscle  is  generally  well 
marked.  If  a  needle  be  thrust  through  this  in- 
terval, quite  close  to  the  clavicle,  it  would  just 
touch  the  bifurcation  of  the  innominate  artery 
on  the  right  side  and  would  pierce  the  carotid 
vessel  on  the  left.  The  posterior  belly  of  the 
digastric  muscle  corresponds  to  a  line  drawn  from 
the  mastoid  process  to  the  anterior  part  of  the 
hyoid  bone.  The  anterior  belly  of  the  omo-hyoid 
follows  an  oblique  line  drawn  downwards  from  the 
fore  part  of  the  hyoid  bone,  so  as  to  cross  the 
line  of  the  carotid  artery  opposite  the  cricoid 
cartilage.  The  posterior  belly  can  be  made  out  in 
thin  necks,  especially  when  in  action,  running 
nearly  parallel  with  and  just  above  the  clavicle. 
Although  not  taking  quite  the  same  direction,  yet 
the  posterior  borders  of  the  sterno-mastoid  and 
anterior  scalene  muscles  practically  correspond 
to  one  another. 

Vessels. — The  common  carotid  artery  is  repre- 
sented by  a  line  drawn  from  the  sterno-clavicular 
joint  to  a  point  midway  between  the  angle  of  the 
jaw  and  the  mastoid  process.  The  vessel  bifur- 
cates at  the  upper  border  of  the  thyroid  cartilage, 
or  not  infrequentlv  nearly  J  an  inch  above  that 
point.  The  omo-hyoid  crosses  it  opposite  the 
cricoid  cartilage,  and  at  about  the  same  level  the 
artery  is  crossed  by  the  middle  thyroid  vein.  The 
line  of  the  internal  jugular  vein  is  just  external 
to  that  for  the  main  artery.  Both  the  artery  and 
vein  lie  under  the  anterior  border  of  the  sterno- 
mastoid.  The  superior  thyroid  artery  comes  off 
below  the  great  cornu  of  the  hyoid  bone,  and 
curves  forwards  and  downwards  to  the  upper 
edge  of  the  thyroid  cartilage.  The  great  cornu  of 
the  hyoid  serves  as  an  excellent  guide  to  the  lin- 
gual artery,  which  invariably  forms  a  loop  above 
the  posterior  end  of  that  process  before  proceeding 
forwards  beneath  the  hyo-glossus  muscle  (Fig. 
32).  The  facial  artery  is  very  tortuous,  but  its 
general  course  in  the  neck  is  represented  by  a  line 


168 


THE    HEAD    AND    NECK 


J  [Chap. 


drawn  from  the  anterior  border  of  the  masseter 
at  the  lower  border  of  the  jaw  to  a  point  just 
above  the  tip  of  the  great  cornu,  while  the  occi- 
pital follows  a  line  that  starts  from  the  latter 
point  and  runs  across  the  base  of  the  mastoid 
process. 

The  external  jugular  vein  follows  a  line  drawn 
from  the  angle  of  the  jaw  to  the  middle  of  the 
clavicle. 


BRACK     PLEX 

Mid.   Point   Clav. 


-    Mid.    Point  Clav. 
Axill.  Art. 


Subclav.  Art. 
Vert.   Art. 


Fig.  39. — Diagram  showing  the  surface  markings  for  the 
brachial  plexus,  subclavian  and  carotid  arteries. 

The  subclavian  artery  describes  a  curve  at  the 
root  of  the  neck  (Fig.  39).  One  end  of  the  curve 
corresponds  to  the  sterno-clavicular  joint,  the  other 
end  to  the  centre  of  the  clavicle,  the  summit  of  the 
curve  rising  to  a  point  about  \  an  inch  above  that 
bone.  In  the  angle  between  the  posterior  edge 
of  the  sterno-mastoid  and  the  clavicle  the  pulsa- 
tions of  the  artery  may  be  felt.  Just  above  the 
bone  the  artery  may  be  compressed  against  the 
first  rib.  The  compression  is  most  easily  applied 
when    the    arm    is    well    drawn    down,    and    the 


1X1  NERVES    OF    THE    NECK  169 

direction   of   the   pressure   should  be   downwards 
and  inwards. 

The  subclavian  vein  lies  below  the  artery,  and 
is  entirely  under  cover  of  the  clavicle. 

The  suprascapular  and  transverse  cervical 
arteries  run  parallel  with  the  clavicle,  the  former 
quite  behind  the  bone,  the  latter  just  above  it. 
The  pulsations  of  the  latter  vessel  can  generally 
be  felt. 

Nerves.— The  position  of  the  chief  superficial 
nerves  of  the  neck  may  be  fairly  indicated  by 
six  lines,  all  drawn  from  the  middle  of  the  pos- 
terior border  of  the  sterno-mastoid  muscle.  A  line 
drawn  forwards  from  this  spot  so  as  to  cross  the 
sterno-mastoid  at  right  angles  to  its  long  axis 
corresponds  to  the  superficial  cervical  nerve.  A 
second  line  drawn  up  across  the  muscle  to  the 
back  of  the  pinna,  so  as  to  run  parallel  with  the 
external  jugular  vein,  corresponds  to  the  great 
auricular  nerve;  and  a  third  line,  running  along 
the  posterior  border  of  the  sterno-mastoid  muscle 
to  the  scalp,  marks  the  course  of  the  small  occi- 
pital nerve.  These  lines,  continued  downwards, 
so  as  to  cross  the  sternum,  the  middle  of  the  cla- 
vicle, and  the  acromion,  will  indicate  respectively 
the  suprasternal,  supraclavicular,  and  supra- 
acromial  nerves. 

The  spinal  accessory  nerve  reaches  the  anterior 
border  of  the  sterno-mastoid  muscle  at  a  point 
about  1  inch  below  the  tip  of  the  mastoid  process. 
It  emerges  from  beneath  that  muscle  about  the 
middle  of  its  posterior  border,  crosses  the  pos- 
terior triangle,  and  passes  beneath  the  trapezius 
between  the  middle  and  lower  thirds  of  the  anterior 
border  of  that  muscle   (Fig.   32,   p.    130). 

The  phrenic  nerve  commences  deeply  at  the 
side  of  the  neck,  about  the  level  of  the  mid-point 
of  the  thyroid  cartilage,  and  runs  downwards 
to  a  point  behind  the  sternal  end  of  the  clavicle. 
About  the  level  of  the  cricoid  cartilage  it  lies 
beneath  the  sterno-mastoid  (which  covers  it  wholly 
in  the  neck)  about  midway  between  the  anterior 

G* 


170  THE    HEAD    AND    NECK  [Chap. 

and  posterior  borders  of  the  muscle.  The  brachial 
plexus  can  be  felt,  and  even  seen  in  very  thin 
subjects.  Its  upper  limits  may  be  represented 
by  a  line  drawn  across  the  side  of  the  neck  from 
a  point  about  opposite  to  the  crico-thyroid  space 
to  a  spot  a  little  external  to  the  centre  of  the 
clavicle. 

The  skin  in  the  submaxillary  region  is  lax 
and  thin,  and  is  often  found  of  considerable  value 
for  making  flaps  in  plastic  operations  about  the 
mouth.  The  platysma  myoides  is  closely  con- 
nected with  the  skin,  and  to  its  action  is  due  the 
turning-in  of  the  edges  of  such  wounds  as  are 
athwart  the  line  of  direction  of  the  muscle.  The 
amount  of  subcutaneous  fat  in  the  cervical  re- 
gion varies  in  different  parts.  In  the  suprahyoid 
region  it  is  apt  to  undergo  extensive  development, 
producing  the  diffused  lipoma  known  as  ■'  double- 
chin.  " 

The  skin  over  the  nape  of  the  neck  is  very 
dense  and  adherent,  and  these  two  circumstances, 
in  addition  to  the  free  nerve-supply  of  the  parts, 
serve  to  explain  the  severe  pain  that  often  accom- 
panies inflammation  in  this  region.  Common  car- 
buncle is  very  often  met  with  behind  at  the  root 
of  the  neck,  in  the  middle  line. 

When  the  stcrno-mastoid  muscle  of  one  side  is 
rigidly  contracted,  either  from  paralysis  of  the 
opposite  muscle  or  from  spasmodic  contraction, 
or  from  some  congenital  defect,  the  condition 
known  as  wry-neck  is  produced.  The  position  of 
the  head  in  wry-neck  illustrates  precisely  the 
effect  of  the  sterno-mastoid  when  in  full  action. 
The  head  is  bent  a  little  forwards,  the  chin  is 
turned  towards  the  sound  side,  and  the  ear  on  the 
affected  side  leans  towards  the  sternoclavicular 
joint.  In  many  cases  the  trapezius  and  splenius 
muscles  are  also  affected.  Spasmodic  contraction 
of  the  muscle  may  be  due  to  reflex  irritation. 
Thus,  it  has  accompanied  inflammation  of  the  cer- 
vical glands  in  the  posterior  triangle.  Such  in- 
flammation   has    irritated    some    branches   of    the 


IX]  THE    STERNO-MASTOID  171 

cervical  plexus,  and  the  sterno-mastoid  muscle, 
although  it  is  supplied  mainly  by  the  spinal  acces- 
sory nerve,  receives  a  nerve  from  that  plexus  (viz. 
from  the  second  cervical).  The  course  of  the  re- 
flex disturbance  in  such  cases  is  therefore  not  dim- 
cult  to  follow.  It  is  to  be  remembered,  too,  that 
the  spinal  accessory  nerve  passes  between  the 
upper  two  or  three  deep  cervical  lymph  glands 
which  may  compress  it.  A  like  contraction  has 
also  been  produced  by  direct  irritation  of  the 
second  cervical  nerve  in  cases  of  disease  of  the 
first  two  cervical  vertebrae.  For  the  relief  of  some 
forms  of  wry-neck,  the  sterno-mastoid  muscle  is 
divided  subcutaneously,  as  in  an  ordinary  teno- 
tomy operation,  about  \  an  inch  above  its  attach- 
ment to  the  sternum  and  clavicle.  Two  structures 
stand  considerable  risk  of  being  wounded  in  this 
operation,  viz.,  the  external  iugular  vein  lying 
near  the  posterior  border  of  the  muscle,  and  the 
anterior  jugular  which  follows  its  anterior  border 
and  passes  behind  the  muscle,  just  above  the 
clavicle,  to  terminate  in  the  first-named  vein. 
With  common  care,  there  should  be  no  risk  of 
wounding  the  great  vessels  at  the  root  of  the  neck. 
For  spasmodic  wry-neck  the  spinal  accessory 
nerve  and  the  communicating  branches  of  the 
second  and  third  cervical  nerves  have  been  cut. 
The  spinal  accessory  nerve  is  found  at  the  an- 
terior border  of  the  sterno-mastoid,  1  inch  below 
the  mastoid  process. 

There  is  a  curious  congenital  tumour,  or  in- 
duration, sometimes  met  with  in  this  muscle  in 
the  newly  born.  It  is  usually  ascribed  to  syphilis, 
but,  in  most  cases,  is  probably  due  to  some  tear- 
ing of  the  muscle  fibres  during  the  process  of 
delivery. 

Cervical  fascia. — To  the  connective  tissue 
which  binds  together  the  muscles,  vessels,  nerves, 
and  glands  of  the  neck  the  name  of  cervical 
fascia  is  given.  It  consists  of  the  sheaths  of 
the  muscles,  vessels,  and  nerves.  These  sheaths 
are    united    together    in    such    a    manner    as    to 


172  THE    HEAD    AND    NECK  ![Chap. 

allow  free  movements  of  the  oesophagus,  larynx, 
and  trachea,  and  yet  to  give  a  firmness  and 
solidity  so  that  the  neck  may  be  moved  as  a 
whole.  Besides  serving  as  a  medium  for  binding 
the  various  structures  of  the  neck  together,  the 
cervical  fascia  forms  the  supporting  tissue  in 
which  the  extensive  lymphatic  system  of  the  neck 
is  embedded  and  conveyed  towards  the  root  of 
the  neck. 

The  deep  cervical  fascia  may  be  divided  into 
(a)  the  superficial  layer,  and  (b)  the  deeper  pro- 
cesses  (see  Fig.   40). 

(a)  The  superficial  layer  forms  a  complete  in- 
vestment for  the  neck,  and  covers  in  all  the  cer- 
vical structures,  except  the  platysma  and  some 
superficial  veins  and  nerves,  with  the  complete- 
ness of  a  perfectly  fitting  cravat.  It  commences 
as  a  thin  layer  behind  at  the  spinous  processes  of 
the  vertebrae,  and,  having  invested  the  trapezius 
muscle,  starts,  at  the  anterior  border  of  that 
muscle,  as  a  single  layer,  to  cross  the  posterior 
triangle.  Arriving  at  the  posterior  border  of  the 
sterno-mastoid  muscle,  it  splits  to  enclose  that 
structure,  appearing  again  as  a  single  layer  at  the 
anterior  border  of  the  muscle,  from  whence  it 
passes  to  the  middle  line  of  the  neck  to  join  the 
fascia  of  the  opposite  side,  entirely  covering  in, 
on  its  way,  the  anterior  triangle.  The  part  that 
occupies  the  posterior  triangle  is  loose  and  open 
in  texture,  and  is  continuous  with  the  connective 
tissue  of  that  triangle.  Over  the  anterior  triangle 
the  fascia  is  attached  above  to  the  border  of  the 
lower  jaw.  Behind  that  bone  it  passes  over  the 
parotid  gland  to  the  zygoma,  forming  the  parotid 
fascia,  while  a  deeper  layer  passes  beneath  the 
gland  (between  it  and  its  submaxillary  colleague), 
to  be  attached  to  points  at  the  base  of  the  skull. 
It  is  from  this  deeper  part  that  the  stylo-maxil- 
lary ligament  is  developed.  In  front  the  fascia 
is  attached  to  the  hyoid  bone,  and  just  belpw  the 
thyroid  body  it  divides  into  two  layers  again,  one 
to  be  attached  to  the  front  of  the  sternum  and  the 


ixi 


CERVICAL    FASCIA 


173 


other  to  the  back.  Both  of  these  layers  lie  in  front 
of  the  depressors  of  the  hyoid  bone,  and  they  form 
between  them  a  little  space  (which  extends  so  far 
laterally  as  to  enclose  the  sternal  head  of  the 
sterno-mastoid),  the  widest  part  of  which  is  below, 
and    which    there    corresponds    in    width    to    the 


Fig.  40. — Transverse  section  through  the  lower  part  of  the 
neck,  to  show  the  arrangement  of  the  cervical  fascia 

{diagrammatic). 

a,  Trapezius  ;  b,  sterno-mastoid  ;  c,  depressors  of  hyoid  bone  ;  d,  pla- 
tysma  ;  e  anterior  spinal  muscles  ;  /,  scalenus  anticus  ;  g,  carotid 
artery  ;  h,  external  jugular  vein  ;  i,  posterior  spinal  muscles  ; 
T,  trachea,  with  gullet  behind  and  thyroid  body  in  front. 

thickness  of  the  sternum.  It  will  be  perceived 
that,  in  dividing  the  sternal  head  of  the  sterno- 
mastoid,  the  operation  is  performed  within  this 
little  chamber  formed  by  the  two  layers  just 
named,  and  it  is  well  to  note  that  the  anterior 
jugular  vein  also  occupies  this  chamber  on  its  way 
to  the  external  jugular  trunk. 


174  THE    HEAD    AND    NECK  [Chap. 

(b)  The  deeper  processes.— (1)  From  the  super- 
ficial layer  a  process  comes  off  near  the  anterior 
border  of  the  sterno-mastoid  muscle,  which,  pass- 
ing beneath  the  depressors  of  the  hyoid  bone,  in- 
vests the  thyroid  body  and  front  of  the  trachea, 
and  passes  down,  in  front  of  that  tube  and  of  the 
large  vessels,  to  the  fibrous  layer  of  the  peri- 
cardium. (2)  The  prevertebral  fascia  is  a  layer 
that  descends  on  the  prevertebral  muscles  behind 
the  pharynx  and  gullet.  It  is  attached  above 
to  the  base  of  the  skull,  and,  below,  descends  into 
the  thorax,  behind  the  oesophagus.  Laterally,  it 
joins  the  carotid  sheath,  and  is  then  prolonged 
outwards  and  downwards  over  the  scalene  muscles, 
the  brachial  plexus,  and  subclavian  vessels.  It 
follows  these  vessels  beneath  the  clavicle,  where 
it  forms  the  axillary  sheath  and  becomes  con- 
nected with  the  under  surface  of  the  costo-cora- 
coid  membrane.  (3)  The  sheath  of  the  carotid 
artery  and  its  accompanying  vein  and  nerve  is 
continuous  with  the  prevertebral  and  pretracheal 
layers  and  with  the  sheath  of  the  sterno-mastoid 
(Fig.  40).  The  carotid  sheath  descends  with  the 
pretracheal  layer,  to  end  in  the^  sheath  of  the 
aorta  and  pericardium.  Hence,  in  a  sense,  the 
heart  and  pericardium  are  supported  from  the 
neck ;  when  the  head  is  thrown  back  the  carotid 
sheaths  become  tense  and  the  thoracic  structures 
are  lifted  upwards. 

In  many  cases  a  cervical  abscess  has  burst  into 
the  gullet,  or  trachea,  and  even  into  the  pleura. 
In  some  instances  the  great  vessels  have  been 
opened  up.  In  one  remarkable  case  reported  by 
Mr.  Savory  (Med.-Chir.  Trans.,  1881),  not  only 
was  a  considerable  portion  of  the  common  carotid 
artery  destroyed  by  the  abscess,  but  also  a  still 
larger  portion  of  the  internal  jugular  vein  and  a 
large  part  of  the  vagus  nerve.  This,  and  like 
examples  of  the  destructive  action  of  some  cervical 
abscesses,  depend,  no  doubt,  upon  the  unyielding 
character  of  the  cervical  fascia,  which  hems  in 
the  pus  on   all  sides,   and  drives  it  to  resort  to 


IX]  APEX    OF    THE    LUNG  175 

desperate  measures  to  effect  an  escape.  "  It  is 
noteworthy, "  remarks  Mr.  Jacobson,  "  that  com- 
munications between  abscesses  and  deep  vessels 
have  usually  taken  place  beneath  two  of  the 
strongest  fasciae  in  the  body,  the  deep  cervical 
fascia  and  the  fascia  lata  "  (Hilton's  "  Rest  and 
Pain  "). 

!  The  apex  of  the  lung  extends  into  the 
neck,  and  reaches  a  point  from  1  to  2  inches 
above  the  inner  half  of  the  clavicle.  A  point 
between  the  sternal  and  clavicular  heads  of  the 
sterno-mastoid  and  lj  inches  above  the  clavicle 
will,  in  the  majority  of  adults,  mark  the  highest 
point  of  the  apex  and  the  position  of  the  neck  of 
the  first  rib.  It  lies  behind  the  clavicle,  anterior 
scalene  muscle,  and  subclavian  vessels.  The  right 
lung  commonly  extends  higher  up  than  the  left. 

The  pleura  has  been  opened  in  careless  opera- 
tions on  the  subclavian  artery,  and  has  also  been 
torn  in  dragging  deep-seated  tumours  from  the 
base  of  the  neck.  The  pleura  and  lung  have  been 
wounded  in  stabs  of  the  neck  and  by  fragments 
of  bone  in  severe  fractures  of  the  clavicle.  Cer- 
vical abscesses  have  opened  into  the  pleura,  and, 
apart  from  this,  pleurisy  has  followed  inflamma- 
tion of  the  cellular  tissue  at  the  root  of  the  neck. 
Sibson's  fascia,  which  is  attached  along  the  inner 
border  of  the  first  rib,  strengthens  the  pleura  over 
the  apex  of  the  lung. 

Cervical  ribs.  —  These  structures  have  led 
to  many  errors  in  diagnosis,  have  been  mistaken 
for  exostoses,  and  where  the  subclavian  artery  is 
carried  over  them,  which  is  usually  the  case  (Fig. 
41),  have  led  to  the  diagnosis  of  aneurysm.  They 
are  met  with  at  all  ages  and  in  both  sexes,  and 
represent  the  cervical  ribs  of  lower  vertebrates. 
In  most  cases  one  such  rib  is  found  on  either  side 
of  the  seventh  cervical  vertebra ;  sometimes  it  is 
movable,  sometimes  it  is  ankylosed  to  the  vertebra 
and  its  transverse  process.  A  rudiment  is  always 
present  in  the  foetus.  It  may  be  very  short,  and 
represented  only  by  a  head,   neck,   and  tubercle. 


176 


THE    HEAT)    AND    NECK 


[Chap. 


Such  forms  have  been  mistaken  for  exostoses. 
It  may  be  long,  and  may  then  end  free,  or  be 
joined  to  the  first  rib  or  the  first  costal  cartilage 
by  ligament,  or  even  by  cartilage.  In  such  in- 
stances the  subclavian  artery  passes  over  the 
cervical  rib,   its  pulsations  being  very  distinctly 


Fifth  Cerv./Ierve 


^Carotid  Tubercle 

Trac/iea 
iElCMTM  Cerv./Ierve 
+Cervical  Rib 
J.5uBCLAviAn  Art. 

Carotid  Art. 

Sibson's  Fascia 
Imomiaiate  Art. 

Clavtcle 


ANUBR.IUM 


Fig.  41.  — Showing  the  relationship  of  the  subclavian  artery 
and  brachial  plexus  to  a  cervical  rib. 

seen  and  felt.  To  the  longer  form  of  cervical  ribs 
the  scalenus  anticus  and  the  scalenus  medius 
may  be  attached.  Occasionally  subjects  of  this 
anomaly  complain  of  numbness  along  the  ulnar 
side  of  the  arm  and  hand,  or  of  partial  paralysis 
of  the  muscles  of  the  hand.  These  symptoms  are 
due  to  traction  on  the  first  dorsal  nerve  at  the 


IX]  WOUNDS    OF    THE    NECK  177 

point  where  it  crosses  above  the  cervical  rib 
(Thorburn).  (See  Fig.  41.)  Cervical  ribs  with 
associated  pressure  symptoms  may  be  traced 
through  several  generations  of  the  same  family 
(Theodore  Thompson).  In  thin  subjects  the  rib 
can  be  seen  as  a  distinct  projection  in  the  neck. 
Dr.  Wood-Jones  has  pointed  out  that  the  groove 
on  the  upper  surface  of  the  first  rib  is  occupied, 
not  by  the  subclavian  artery,  but  by  the  lowest 
trunk  of  the  brachial  plexus  formed  by  the  eighth 
cervical  and  first  dorsal  nerves.  He  has  also 
shown  that  the  groove  is  deepest,  and  the  pres- 
sure between  the  nerve  trunk  and  rib  therefore 
greatest,  in  those  cases  where  a  considerable  part 
of  the  second  dorsal  nerve  enters  into  the  forma- 
tion of  the  lowest  trunk  of  the  brachial  plexus. 

Cut  throat  and  wounds  of  the  neck.— 
The  skin  of  the  neck  is  so  elastic  and  mobile  that 
it  is  readily  thrown  into  folds  when  a  knife, 
and  especially  a  blunt  knife,  is  drawn  across  it. 
Thus  in  cases  of  cut  throat  several  distinct  skin- 
cuts  may  be  found  that  were  all  produced  by  one 
movement  of  the  knife.  The  wound  in  cut  throat, 
whether  suicidal  or  homicidal,  most  frequently 
involves  the  thyro-hyoid  membrane,  next  in  fre- 
quency the  trachea,  and  then  the  thyroid  car- 
tilage.    (See  Fig.  39.) 

1.  If  the  wound  be  above  the  hyoid  bone  the 
following  parts  may  be  cut  :  Anterior  jugular 
vein ;  anterior  belly  of  digastric ;  mylo-hyoid, 
genio-hyoid,  genio-hyo-glossus,  and  hyo-glossus 
muscles ;  the  lingual  artery ;  branches  of  the  facial 
artery;  the ^  hypoglossal  and  gustatory  nerves; 
the  submaxillary  gland.  The  substance  of  the 
tongue  may  be  cut,  and  the  floor  of  the  mouth 
freely  opened.  In  any  case  where  the  attachments 
of  the  tongue  are  divided  the  organ  is  apt  to  fall 
back  upon  the  larynx  and  produce  suffocation. 

2.  If  the  wound  be  across  the  thyro-hyoid  space 
the  following  may  be  the  parts  cut :  Anterior 
jugular  vein;  sterno-hyoid,  thyro-hyoid,  omo- 
hyoid  muscles;   thyro-hyoid   membrane;    inferior 


178  THE    HEAD    AND    NECK  [Chafe. 

constrictor ;  superior  laryngeal  nerve ;  superior 
thyroid  artery;  and  if  near  the  hyoid  bone  the 
trunk  of  the  lingual  artery  may  be  cut.  The 
pharynx  would  be  opened  in  a  deep  wound,  and 
the  epiglottis  divided  near  its  base.  Division  of 
the  epiglottis  in  wounds  in  this  situation  is  always 
a  serious  complication. 

3.  If  the  wound  involve  the  trachea  the  follow- 
ing may  be  the  parts  cut :  Anterior  jugular 
vein ;  sterno-hyoid,  sterno-thyroid,  and  omo-hyoid 
muscles ;  part  of  sterno-mastoid ;  thyroid  gland ; 
superior  and  inferior  thyroid  arteries;  superior, 
middle,  and  inferior  thyroid  veins;  recurrent 
laryngeal  nerves  and  the  gullet. 

In  wounds  of  the  neck  the  great  vessels  often 
escape  in  a  marvellous  manner.  They  are  pro- 
tected in  part  by  the  depth  at  which  they  are 
situated,  and  in  part  by  their  great  mobility, 
lying  as  they  do  in  an  atmosphere  of  loose  con- 
nective tissue.  Dieffenbach  relates  a  case  of  cut 
throat  in  which  both  gullet  and  trachea  were 
divided  without  any  damage  to  the  great  vessels. 
In  cut  throat  the  vessels  are  greatly  protected 
by  the  projecting  thyroid  cartilage  above  and  by 
the  contracting  of  the  sterno-mastoid  muscles 
below.  Deep  gashes  made  across  the  crico-thy- 
roid  space,  or  through  the  upper  part  of  the 
trachea,  reach  the  great  vessels  more  easily  than 
would  wounds  made  with  equal  force  in  any  other 
part  of  the  neck. 

In  some  cases  of  gunshot  wound  the  vessels 
seem  to  have  been  actually  pushed  aside,  and  to 
have  owed  their  safety  to  their  mobility.  Thus, 
in  a  case  reported  by  Longmore,  the  bullet  passed 
entirely  through  the  neck  from  one  side  to  the 
other.  It  passed  through  the  gullet,  damaged  the 
posterior  part  of  the  larynx,  but  left  the  great 
vessels  intact.  In  another  recorded  case  a  boy 
fell  upon  the  point  of  a  walking-stick.  The  end 
of  the^  stick  passed  entirely  through  the  neck 
from  side  to  side,  entering  in  front  of  one  sterno- 
mastoid   muscle   and   emerging   through   the   sub- 


IX]  HYOID    BONE  179 

stance  of  the  opposite  one.  It  probably  passed 
between  the  pharynx  and  the  spine.  The  boy, 
who  left  the  hospital  well  in  eighteen  days,  owed 
his  safety  to  the  laxity  of  the  cervical  connective 
tissue  and  to  the  mobility  of  the  main  structures 
in  the  neck.  The  structures  of  the  neck  are  fixed 
laxly  to  allow  movements  of  the  larynx  and 
tongue. 

In  connexion  with  the  subject  of  wounds  of  the 
neck,  it  must  be  remembered  that  the  most  im- 
portant part  of  the  spinal  cord  can  be  reached 
from  behind,  through  the  gap  between  the  atlas 
and  axis.  In  this  situation  the  cord  has  been 
divided  by  one  stab  of  a  knife,  the  instrument 
entering  between  the  two  bones.  Langier  gives 
some  ingenious  cases  of  infanticide  where  the 
lethal  weapon  was  merely  a  long^  needle.  The 
needle  was  introduced  into  the  spinal  canal  be- 
tween the  atlas  and  the  axis,  and  the  cord  readily 
cut  across. 

The  hyoid  bone  maybe  broken  by  direct  vio- 
lence, as  from  blows,  or  in  the  act  of  throttling. 
It  is  sometimes  found  broken  in  those  who  have 
been  hanged.  The  fracture  may  involve  the  body 
of  the  bone,  but  more  usually  the  greater  cornu 
is  found  broken  off.  In  the  New  York  Medical 
Record  (1882)  is  published  the  report  of  the  case 
of  a  man  who  felt  something  snap  under  his  chin 
while  yawning.  On  examination  the  hyoid  bone 
was  found  to  be  fractured.  The  bone  was  also 
found  broken  in  a  patient  who  threw  her  head 
violently  backwards  to  save  herself  from  fall- 
ing (Hamilton).  The  fracture  is  associated  with 
great  difficulty  and  pain  in  speaking,  in  moving 
the  tongue,  in  opening  the  mouth,  and  in  swallow- 
ing— symptoms  that  may  be  readily  understood. 
A  bursa  lies  between  the  thyro-hyoid  membrane 
and  the  posterior  surface  of  the  hyoid^  bone.  It 
may,  when  enlarged,  form  one  of  the  cystic  tumours 
of  the  neck. 

f^arynx  and  trachea.— The  position  of  the 
larynx  in  the  neck  is  influenced  by  age.     In  the 


180  THE    HEAD    AND    NECK  [Chap. 

adult  the  cricoid  cartilage  reaches  to  the  lower 
part  of  the  sixth  cervical  vertebra.  In  a  child 
of  three  months  it  reaches  the  lower  border  of 
the  fourth  cervical,  and  in  a  child  of  six  years 
the  lower  border  of  the  fifth  vertebra.  At  puberty 
it  attains  the  adult  position.  The  upper  end  of 
the  epiglottis  in  the  adult  is  opposite  the  lower 
border  of  the  third  cervical  vertebra.  With  the 
laryngoscope  the  following  parts  may  be  made 
out  (Fig.  42)  :  The  base  of  the  tongue  and  glosso- 
epiglottic  ligaments ;  the  superior  aperture  of 
the  larynx,  presenting  in  front  the  epiglottis, 
at  the  sides  the  aryteno-epiglottidean  folds  (in 
which  are  two  rounded  eminences  corresponding 
to  the  cornicula  and  cuneiform  cartilages),  and  at 
the  back  the  arytenoid  commissure  of  mucous 
membrane.  Deeply  down  can  be  seen  the  true  and 
false  vocal  cords,  the  ventricle,  the  anterior  wall 
of  the  larynx,  a  little  of  the  cricoid  cartilage, 
and  more  or  less  of  the  anterior  wall  of  the 
trachea.  >  If  the  glottis  be  very  fully  dilated 
the  openings  of  the  two  bronchi  may  be  dimly 
seen. 

The  thyroid  and  cricoid  cartilages  and  the 
greater  part  of  the  arytenoid  are  in  structure 
hyaline,  as  are  the  costal  cartilages.  Like  the 
last-named,  they  are  liable  to  become  more  or  less 
ossified  as  life  advances.  Ossification  commences 
in  the  thyroid  and  cricoid  cartilages  at  about 
the  age  of  20,  and  in  either  cartilage  the  process 
commences  in  the  vicinity  of  the  crico-thyroid 
joint.  The  arytenoid  ossifies  later.  Ossification 
of  the  laryngeal  cartilages  is  more  marked  in 
males  than  in  females.  The  larger  cartilages  are 
liable  to  be  fractured  by  violence,  as  by  blows, 
throttling,  etc.  The  thyroid  is  the  one  most  fre- 
quently broken,  and  usually  in  the  median  line. 
The  posterior  superior^  angle  of  the  thyroid  car- 
tilage marks  the  position  of  the  pyriform  fossa, 
a  wide  recess,  above  and  external  to  the  aryteno- 
epiglottic  folds  (Fig.  42).  Foreign  bodies  may 
be  arrested  in  this  fossa. 


IX]  RIMA    GLOTTIDIS  181 

The  rima  glottidis  is  the  aperture  between  the 
true  vocal  cords  and  the  vocal  processes  of  the 
arytenoid,  to  which  the  cords  are  attached  pos- 
teriorly. The  cords  are  double  the  length  of  the 
processes,  and  are  of  a  grey  buff  colour,  owing 
to  the  elastic  tissue,  of  which  they  are  mainly 
composed,  being  apparent  beneath  the  stratified 
epithelium.  The  rima  is  the  narrowest  part  of 
the  interior  of  the  larynx,  and  it  is  well  to  be 
familiar  with  its  proportions  in  reference  to  the 


Fig.  42.  —Upper  aperture  of  the  larynx  in  the  open  (A)  and 
shut  (b)  positions. 

A,  Cushion  of  epiglottis  ;  B,  apices  of  arytenoids  ;  C,  aryteno-epi- 
glottidean  folds ;  E,  posterior  aspect  of  cricoid ;  F,  false  vocal 
cords  ;  G,  rima  glottidis,  between  true  vocal  cords  ;  H,  posterior 
border  of  thyroid  cartilage  ;  I,  tip  of  great  horn  of  hyoid. 

entrance  of  foreign  bodies  and  the  introduction 
of  instruments.  In  the  adult  male  the  rima  mea- 
sures nearly  1  inch  (23  mm.)  from  before  back- 
wards; from  side  to  side,  at  its  widest  part,  it 
measures  about  one-third  of  the  length ;  this  dia- 
meter may  be  increased  to  one-half  of  the  length 
in  extreme  dilatation.  In  the  female  and  in  the 
male  before  puberty  the  antero-posterior  diameter 
is  from  17  mm.  The  rima  is  widely  opened  dur- 
ing inspiration,  owing  to  the  action  of  the  crico- 
arytenoideus  posticus,   while  the  vocal  cords  are 


182  THE    HEAD    AND    NECK  [Chap. 

approximated  in  speech  under  the  influence  of  the 
crico-arytenoideus   lateralis. 

The    mucous   membrane   of    the    larynx    varies 
in  thickness  in  different  parts,  and  in  the  amount 
of  its  submucous  tissue.     The  membrane  is  thick- 
est, and  the  submucous  tissue  most  abundant,  in 
.the   following   parts,    taken   in   order   of   degree  : 
The  aryteno-epiglottidean  folds,  the  mucous  mem- 
brane of  the  ventricle,   the  false  cords,   and  the 
laryngeal  aspect  of  the  epiglottis.     These  are  the 
parts  that  become  most  congested  and  swollen  in 
acute  laryngitis ;  and  the  serious  condition  known 
as   oedema   of   the   glottis    depends   mainly    upon 
effusion    into    the    lax    submucous    tissue    in    the 
aryteno-epiglottidean  folds.     The  lax  condition  of 
the  mucous  membrane  of  the  aryteno-epiglottidean 
folds    allows    free    movements    of    the    arytenoid 
cartilages    and    complete    closure    of    the    upper 
aperture  of    the   larynx    (Fig.    42).     The   mucous 
membrane  is  firmly  bound  to  the  true  vocal  cords 
and   covered  by   stratified   epithelium,    while   the 
rest  of  the  larynx  is  lined,  like  the  trachea,  with 
ciliated  epithelium.     Owing  to  the  nature  of  its 
covering  and  exposure  to  friction,  the  true  vocal 
cord    is   not   an    uncommon    site    of    epithelioma. 
The  affection  known  as  "clergyman's  sore  throat" 
has  an  interesting  anatomical  basis.     The  mucous 
membrane   of   the   larynx   is   well   provided   with 
mucous  glands,  whose  function  it  is  to  keep  moist 
the  parts  concerned  in  phonation.     When  an  in- 
dividual speaks  aloud  for  a  t  long  time  the  lining 
of   the   larynx  tends   to   become   dry,    on   account 
of   the   large   amount  of  cold  air  that  is   drawn 
in    directly   through   the   mouth.      To   keep    these 
parts  moist  the   mucous   glands  have   to   exhibit 
increased  energy,   and  in  those  who  speak  much 
in  public  the  glands  may  in  time  become  so  over- 
worked   as   to    inflame.      It    is   the    inflammation 
of  these  glands  that  constitutes  the  present  affec- 
tion.    The  glands  are  not  distributed  equally  over 
all   parts  of  the  larynx,   but  are  most  numerous 
in  the  membrane  covering  the  arytenoid  cartilages 


IX]  EXCISION   OF    THE    LARYNX  183 

and  parts  immediately  about  them,  the  base  of 
the  epiglottis,  and  the  interior  of  the  ventricle. 
It  is  in  these  parts,  therefore,  that  the  changes 
in  chronic  glandular  laryngitis,  or  dysphonia 
clericorum,  are  most  marked. 

Excision  of  the  larynx. — The  entire  larynx  has 
been  removed  for  carcinomatous  disease,  but  the 
operation,  although  not  immediately  fatal,  has 
not  been  followed  by  very  satisfactory  results. 
It  is  removed  through  an  incision  in  the  middle 
line.  In  this  incision  are  divided  the  platysma, 
the  fascia,  and  the  anterior  jugular  vein.  The 
larynx  is  separated  from  its  connexions,  the  fol- 
lowing structures  being  divided  :  sterno-thyroid, 
thyro-hyoid,  stylo-pharyngeus,  palato-pharyngeus, 
and  inferior  constrictor  muscles,  the  laryngeal 
branches  of  the  superior  and  inferior  thyroid 
arteries,  superior  and  inferior  laryngeal  nerves, 
hyo-epiglottic  and  glosso-epiglottic  ligaments.  The 
larynx  is  then  separated  from  the  trachea,  and  is 
dissected  off  from  below  up.  In  separating  the 
gullet  and  pharynx  there  is  great  risk  of  "  button- 
holing "  the  former  tube.  Growths  and  foreign 
bodies  may  be  removed  from  the  larynx  by  the 
operation  of  thyrotomy :  the  two  alse  of  the  thyroid 
are  separated  along  the  middle  line  and  pulled 
apart,  thus  exposing  the  interior  of  the  larynx. 
In  subjects  over  45  years  of  age  the  cartilage  be- 
comes ossified  in  the  middle  line,  and  will  require 
division  by  a  fine  saw.  It  should  be  remembered 
that  the  vocal  cords  are  attached  on  each  side  of 
the  median  line  near  the  mid-point  of  the  anterior 
border  of  the  thyroid  cartilage,  while  just  above 
them  are  fixed  the  false  vocal  cords  and  stalk  of 
the  epiglottis. 

The  lymphatic  vessels  of  the  upper  half  of  the 
larynx  follow  the  superior  laryngeal  vessels  and 
pass  to  the  upper  deep  cervical  glands.  A  small 
lymphatic  gland,  the  first  to  become  the  seat  of 
secondary  cancerous  #  deposit,  is  situated  below 
the  horn  of  the  hyoid  on  the  thyrohyoid  mem- 
brane  (Fig.    44,    p.    197).      The  lymphatics  of  the 


184  THE    HEAD    AND    NECK  '[Chap. 

lower  half  of  the  larynx  accompany  the  inferior 
thyroid  vessels  and  pass  through  lymph  glands 
by  the  side  of  the  trachea. 

Tracheotomy  and  laryngotomy. — The  trachea 
is  about  4j  inches  in  length,  and  from  f  to 
1  inch  in  its  extreme  width.  It  is  surrounded 
by  an  atmosphere  of  very  lax  connective  tissue, 
which  allows  a  considerable  degree  of  mobility  to 
the  tube.  The  mobility  of  the  trachea  is  greater 
in  children  than  in  adults,  and  adds  much  to  the 
difficulties  of  tracheotomy.  In  this  procedure  the 
windpipe  is  opened  in  the  middle  line  by  cutting 
two  or  three  of  its  rings  above,  below,  or  through 
the  isthmus  of  the  thyroid  gland.  Since  the 
trachea,  as  it  descends,  lies  farther  from  the  sur- 
face, and  comes  in  relation  with  more  and  more 
important  structures,  it  is  obvious  that,  other 
things  being  equal,  the  higher  in  the  neck  the 
operation  can  be  done  the  better.  The  length  of 
trachea  in  the  neck  is  not  so  considerable  as 
might  at  first  appear,  and,  according  to  Holden, 
not  more  than  some  seven  or  eight  of  the  tracheal 
rings  (which  number  sixteen  to  twenty  in  all)  are 
usually  to  be  found  above  the  sternum.  The  dis- 
tance between  the  cricoid  cartilage  and  the  sternal 
notch  varies  greatly,  and  depends  upon  the  length 
of  the  neck,  the  age  of  the  patient,  and  the  posi- 
tion of  the  head.  If  2  inches  of  trachea  are  ex- 
posed above  the  sternum  when  the  head  rests  easily 
upon  the  spine,  then  in  full  extension  of  the  head 
some  |  of  an  inch  more  of  the  windpipe  will^  as 
it  were,  be  drawn  up  into  the  neck.  According 
to  Tillaux,  the  average  full  distance  between  the 
cricoid  cartilage  and  the  sternum  is,  in  the  adult, 
about  2f  inches  (7  cm.).  The  full  distance  in  a 
child  between  3  and  5  years  is  about  H  inches 
(4  cm.),^  in  a  child  between  6  and  7  years 
about  2  inches  (5  cm.),  and  in  children  between 
8  and  10  years  about  2|  inches  (6  cm.).  As 
may  be  imagined,  the  dimensions  of  the  trachea 
on  section  vary  greatly  at  different  ages,  and  even 
in    different   individuals   of   the   same   age.     This 


IX]  TRACHEOTOMY  185 

leads  to  the  question  as  to  the  proper  diameter 
of  tracheotomy  tubes.  Guersant,  who  has  paid 
much  attention  to  this  matter,  says  that  the  dia- 
meter of  the  tubes  should  run  from  6  mm.  to 
15  mm.*  The  tubes  with  a  diameter  of ,  from 
12  mm.  to  15  mm.  are  for  adults.  For  children 
under  eighteen  months  the  diameter  of  the  tube 
should  be  about  4  mm. 

In  performing  tracheotomy  it  is  most  im- 
portant that  the  head  be#  thrown  as  far  back  as 
possible,  and  that  the  chin  be  kept  strictly  in  a 
line  with  the  sternal  notch,  so  that  the  relations 
of  the  middle  line  of  the  neck  be  preserved.  Full 
extension  of  the  head  not  only  gives  the  surgeon 
increased  room  for  the  operation,  but  also  brings 
the  trachea  nearer  to  the  surface,  and  by  stretch- 
ing the  tube  renders  it  much  less  mobile. 

^  In  cutting  down  unon  the  trachea  in  tKe 
middle  line  of  the  neck  from  the  cricoid  cartilage 
to  the  sternum  the  following  parts  are^  met  with  : 
Beneath  the  integument  lie  the  anterior  jugular 
veins.  As  a  rule  these  veins  lie  some  little  way 
apart  on  either  side  of  the  median  line,  and  do 
not  communicate  except  ^  by  a  large  transverse 
branch  which  lies  in  the  interfascial  space  at  the 
upper  border  of  the  sternum.  Sometimes  there 
are  many  communicating  branches  right  in  front 
of  the  tracheotomy  district,  or  the  veins  may 
form  almost  a  plexus  in  front  of  the  trachea,  or 
there  may  be  a  single  vein  which  will  follow  the 
middle  line.  Then  comes  the  cervical  fascia, 
enclosing  the  sterno-hyoid  and  stern  o-thyroid 
muscles.  The  gap  between  the  muscles  of  opposite 
sides  is  lozenge-shaped,  and  is  such  that  the 
trachea  can  he,  exposed  without  dividing  muscle 
fibres.  The  isthmus  of  the  thyroid  usually  crosses 
the  second,  third,  and  fourth  rings  of  the  trachea. 
Above  it  a  transverse  communicating  branch  be- 
tween the  superior  thyroid  veins  is  sometimes 
found.     Over  the  isthmus  is  a  venous  plexus,  from 

*  The  reader  may  be  reminded  that  12  mm.  =  about  h  an  inch,  an 
6  mm.,  therefore,  =  about  £"of  an  inch. 


186  THE    HEAD    AND    NECK  [Chap. 

which  the  inferior  thyroid  veins  arise,  while  be- 
low the  isthmus  these  veins  lie  in  front  of  the 
trachea  together  with  the  thyroidea  ima  artery 
(when  it  exists).  The  inferior  thyroid  vein  may 
be  represented  by  a  single  trunk  occupying  the 
middle  line.  In  the  infant  before  the  age  of  two 
years  the  thymus  extends  up  for  a  variable  dis- 
tance in  front  of  the  trachea.  At  the  very  root 
of  the  neck  the  trachea  is  crossed  by  the  innomi- 
nate and  left  carotid  arteries  and  by  the  left 
innominate  vein ;  and  lastly,  abnormal  branches 
of  the  superior  thyroid  artery  may  cross  the 
upper  rings  of  the  windpipe. 

The  evil  of  wounding  the  thyroid  isthmus  is 
greatly  exaggerated.  I  have  frequently  divided 
this  structure  in  performing  tracheotomy,  without 
any  inconvenience  resulting.  Like  other  median 
raphes,  the  middle  line  of  the  thyroid  isthmus  has 
but  a  slight  vascularity,  and  it  has  been  shown 
that  one  side  of  the  thyroid  gland  cannot  be  in- 
jected from  the  other  (i.e.  by  injection  that  would 
cross  the  isthmus).  The  difficulty  of  tracheotomy 
in  infants  depends  upon  the  shortness  of  the 
neck,  the  amount  of  the  subcutaneous  fat,  the 
depth  at  which  the  trachea  lies,  its  small  size,  its 
great  mobility,  and  the  ease  with  which  it  can  be 
made  to  collapse  on  pressure.  To  the  finger, 
roughly  introduced,  the  infant's  trachea  offers 
little  resistance.  Its  mobility  is  such  that  we 
hear  of  its  being  held  aside  unknowingly  by  re- 
tractors while  the  operator  is  scoring  the  oeso- 
phagus (Durham).  In  the  child,  too,  the  great 
vessels  often  cross  the  trachea  higher  up  than  in 
the  adult,  and  some  inconvenience  may  also  arise 
from  an  unduly  prominent  thymus.  In  one  case, 
in  an  infant,  the  end  of  a  tracheotomy  tube  press- 
ing on  the  front  of  the  trachea  produced  an  ulcer 
that  opened  the  innominate  artery  (Brit.  Med. 
Journ.,  1885).  In  introducing  the  cannula,  if  the 
tracheal  wound  be  missed,  it  is  easy  to  thrust  the 
instrument  into  the  lax  tissue  beneath  the  cervical 
fascia  and  imagine  that  it  is  within  the  windpipe. 


IX]  LARYNGOTOMY  187 

In  laryngotomy  the  air-passage  is  opened  by 
a  transverse  cut  through  the  crico-thyroid  mem- 
brane. The  crico-thyroid  space  only  measures 
about  \  an  inch  in  vertical  height  in  well- 
developed  adult  subjects,  while  in  children  it  is 
much  too  small  to  allow  of  a  cannula  being  in- 
troduced. The  crico-thyroid  arteries  cross  the 
space,  and  can  hardly  escape  division.  They  are, 
as  a  rule,  of  very  insignificant  size,  and  give  no 
trouble.  Occasionally,  however,  these  vessels  are 
large,  and  "  cases  are  recorded  in  which  serious 
and  even  fatal  haemorrhage  has  occurred  from 
these  vessels"  (Durham).  .  In  introducing  the 
cannula  it  may  readily  slip  between  the  crico- 
thyroid membrane  and  the  mucous  lining  instead 
of  entering  the  trachea. 

Foreign  bodies  often  find  their  way  into  the 
air-passages,  and  they  have  been  represented  by 
articles  of  food,  teeth,  pills,  buttons,  small  stones, 
and  the  like.  They  are  usually  inspired  during 
the  act  of  respiration,  and  may  lodge  in  the 
superior  aperture  of  the  larynx,  or  in  the  rirna, 
or  find  their  way  into  the  ventricle,  or  lodge  in 
the  trachea,  or  enter  a  bronchus.  If  a  foreign 
substance  enters  a  bronchus  it  usually  selects 
the  right,  that  bronchus  having  its  aperture  more 
immediately  under  the  centre  of  the  trachea  than 
has  the  left  tube.  On  one  occasion,  in  a  dissecting- 
room  subject,  I  found  two  threepenny  pieces  lying 
side  by  side,  in  the  right  bronchus,  so  as  en- 
tirely to  block  the  tube.  The  danger  of  inhaled 
foreign  substances  depends  not  so  much  upon  the 
mechanical  obstruction  they  offer,  as  upon  the 
spasm  of  the  glottis  they  excite  by  reflex  irrita- 
tion. A  body  may,  however,  lodge  in  the  ventricle 
for  some  time  without  causing  much  trouble,  as 
in  a  case  reported  bv  Desault,  where  a  cherry- 
stone lodged  for  two  years  in  this  cavity  without 
much  inconvenience  to  its  host.^  In  one  strange 
case  a  bronchial  gland  found  its  way  into  the 
trachea  by  producing  ulceration  of  that  tube,  was 
coughed   up,    and  became   impacted   in   the   rima 


188 


THE    HEAD    AND    NECK 


[Chap. 


glottidis.     The  patient  was  saved  from  immediate 
suffocation  by  tracheotomy. 

Thyroid  body. — Eachlobe  of  this  body  should 
measure  about  2  inches  in  lengthy  l\  inches  in 
breadth,  and  j  of  an  inch  in  thickness  at  its 
largest  part.  When  distinctly  beyond  these  mea- 
surements the  thyroid ^  may  be  considered  to  be 
enlarged.  Its  usual  weight  is  between  one  and  two 
ounces.  Of  its  three  surfaces  (Fig.  43),  the  ante- 
rior is  covered  by  the  infrahyoid  muscles,  its  inner 


Ant.  Juq.  Vein     Tra.che* 


Sterno-Hyoid 

Sternothyroid 

Sterno-Mastoid 


Juq.  Vein 
Carotid  Art. 
Recurrent  Laryng.   N. 
Trachea 
CEsophagu 


OMOHYOID 

Inf.   Thyroid  Art. 
Vert.  Art. 


Thyroid  Body 


Fig.  43. — Diagrammatic   section  to  show  the  relations  of 
the  thyroid  body. 


rests  on  the  larynx  and  trachea,  while  its  outer 
or  posterior^  covers  the  carotid  sheath.  Its  promi- 
nent posterior  border  is  in  contact  at  its  lower 
part  with  the  recurrent  laryngeal  nerve  and 
oesophagus.  Each  lobe  extends  from  about  the 
middle  of  the  thyroid  cartilage  to  the  sixth  ring 
of  the  trachea.  It  is  larger  in  females  than  in 
males,  and  the  right  lobe  is  usually  larger  than 
the  left.  In  connexion  with  these  matters  it  may 
be  noted  that  thyroid  enlargements  (bronchocele, 
goitre)  are  more  common  in  females  than  in 
males,  and  in  any  case  are  more  apt  to  be    first 


IX  THYROID    BODY  189 

noticed  on  the  right  side.  The  body  being  closely 
adherent  to  the  trachea  and  larynx,  it  follows 
that  it  moves  up  and  down  during  deglutition, 
and  this  circumstance  is  of  the  utmost  value  in 
the  diagnosis  of  bronchocele  from  other  cervical 
tumours.  A  strong  process  of  cervical  fascia  (the 
suspensory  ligament  of  Berry)  binds  the  gland  to 
each  side  of  the  cricoid  cartilage,  and  has  to  be 
severed  before  complete  removal  is  possible.  The 
thyroid  when  enlarged  may  distort  and  narrow 
the  trachea,  and  this  is  all  the  more  likely  to  be 
the  case  when  the  enlargement  occurs  rapidly, 
since  the  body  is  held  down  by  the  sterno-hyoid, 
sterno-thyroid,  and  omo-hyoid  muscles.  The  pos- 
terior or  outer  surface  of  the  thyroid  body  being 
in  contact  with  the  sheath  of  the  great  vessels, 
it  follows  that  the  gland  when  enlarged  may 
readily  receive  pulsations  from  those  vessels  (Fig. 
43).  It  generally  touches  also  the  lower  part  of 
the  pharynx,  and  the  upper  part  of  the  gullet 
behind,  and  enlargement  in  this  direction  may,  in 
connexion  with  the  interference  with  the  move- 
ment of  the  larynx  in  deglutition,  serve  to  ex- 
plain the  difficulty  in  swallowing  often  noticed 
in  bronchocele. 

The  isthmus  of  the  thyroid  gland  is  developed 
from  a  diverticulum  which  is  protruded  from  the 
ventral  wall  of  the  pharynx  in  the  embryo  between 
the  mandibular  and  hyoid  parts  of  the  tongue 
(Fig.  45,  p.  201).  The  f  foramen  caecum  of  the 
tongue  represents  the  point  at  which  the  diverti- 
culum grew  out  from  the  pharynx.  From  this 
foramen  a  duct  (the  thyro-glossal)  may  be  found 
to  lead  to  accessory^  gland  masses  about  the  hyoid 
bone.  In  the  vicinity  t  of  this  bone  accessory 
glands  and  small  cysts  lined  with  epithelium  are 
not  infrequently  met  with.  These  glands,  to- 
gether with  the  so-called  pyramid  or  middle  lobe, 
are  the  remains  of  the  neck  of  the  primitive  diver- 
ticulum. Below  the  level  of  the  hyoid  bone  the 
median  bud  divides ;  hence  the  pyramidal  lobe 
represents  the  stalk  of  the   right  or   of  the   left 


100  THE    HEAD    AND    NECK  [Chap. 

division  and  is  never  in  the  median  line.  The 
pyramid,  which  is  nearly  always  connected  to  the 
hyoid  bone  by  the  levator  thyroidese,  exists  in  79 
per  cent,  of  the  subjects  examined  (Streckeisen). 
The  lateral  lobes  are  developed  from  the  fourth 
visceral  clefts  (Fig.  45).  The  median  diverticulum 
occasionally  fails  to  join  one  of  the  lateral,  in 
which  case  the  isthmus  is  partially  absent.  Small 
accessory  thyroid  bodies  are  frequently  present. 

The  parathyroid  bodies  appear  to  play  an 
essential  part  in  the  function  of  the  thyroid. 
They  are  of  the  size  of  small  peas,  and  have  a 
structure  similar  to  that  of  the  ^  medulla  of  the 
suprarenal  bodies,  the  cells  being  grouped  in 
reticulating  columns.  Two  are  usually  found  on 
each  side,  one  behind  the  lower  pole  of  the  lateral 
lobe,,  the  other  behind  the  lobe  amongst  the  ter- 
minal branches  of  the  inferior  thyroid  artery. 
Parathyroid  bodies  become  less  numerous  as  age 
advances,  so  that  in  the  aged  none  may  be  found 
(Forsyth).  The  parathyroid  bodies  may  develop 
vesicles  containing  colloid  material,  and  thus  be- 
come very  similar  to  small  accessory  thyroids. 

Atrophy  of  the  thyroid  gland,  or  its  destruc- 
tion by  disease,  is  apt  to  lead  to  a  general  con- 
dition of  the  body  known  as  myxoedema.  The 
condition  closely  resembles  cretinism,  especially  as 
met  with  in  goitrous  subjects.  Myxoedema  may 
follow  the  entire  excision  of  the  gland  by  opera- 
tion, and  has  been  produced  in  monkeys  by  ex- 
perimental removal  of  the  same.  One  prominent 
feature  of  myxoedema  is  the  swelling  of  the  sub- 
cutaneous tissues  from  an  accumulation  therein 
of  a  mucinoid  substance. 

Vasometer  nerves  reach  the  thyroid  through 
the  lower  part  of  the  cervical  sympathetic  chain, 
and  by  the  same  course  nerves  pass  upwards  to 
the  eye.  These  nerves  appear  to  be  connected  cen- 
trally, probably  in  the  medulla,  for  in  certain 
conditions  enlargement  of  the  thyroid  is  accom- 
panied bv  protrusion  of  the  eye  (exophthalmic 
goitre).     The  lymphatics  of  the  thyroid  gland  are 


IX]  THE    (ESOPHAGUS  101 

numerous,  and  pass  to  the  deep  cervical  and 
superior  mediastinal  lymph  glands.  Asher  and 
Flack  found  that  the  internal  secretion  of  the 
thyroid  body  could  be  increased  by  stimulation  of 
the  laryngeal  nerves. 

The  superior  thyroid  artery  reaches  the  gland 
at  the  apex  of  the  lateral  lobe;  the  inferior 
thyroid  artery  enters  the  lower  part  of  the  lobe 
at  its  posterior  aspect.  In  securing  this  vessel, 
and  in  liberating  the  lower  part  of  the  gland 
during  excision,  the  recurrent  laryngeal  nerve  is 
in  great  danger  of  being  damaged.  The  thyroidea 
ima  artery,  an  extra  vessel  to  the  thyroid  body, 
usually  arises  from  the  innominate,  and  is  found 
in  one  subject  out  of  every  ten. 

The  gullet  commences  opposite  the  sixth 
cervical  vertebra,  and  pierces  the  diaphragm 
opposite  the  tenth  dorsal  vertebra.  The  point  is 
marked  on  the  back  by  the  overlapping  spine  of 
the  ninth  dorsal  vertebra.  By  placing  the  stetho- 
scope a  little  to  the  left  of  this  spine,  fluid  may 
be  heard  to  enter  the  stomach.  The  gullet  pre- 
sents three  curves  :  one  is  antero-posterior,  and 
corresponds  to  the  curve  of  the  spinal  column ;  the 
other  two  are  lateral.  Commencing  at  the  middle 
line,  it  deviates  slightly  to  the  left  as  far  as  the 
root  of  the  neck;  from  thence  to  the  fifth  dorsal 
vertebra  it  gradually  returns  to  the  middle  line, 
and  finally  it  turns  again  to  the  left,  at  the  same 
time  passing  forwards5  to  pierce  the  diaphragm. 
Its  length  is  from  9  to  10  inches.  There  are  three 
narrow  parts  in  the  gullet — one  at  its  commence- 
ment, one  about  2|  inches  from  that  point,  and 
a  third  where  the  tube  passes  through  the  dia- 
phragm. The  narrowing  at  the  commencement 
and  termination  of  the  oesophagus  is  due  to  the 
fact  that  the  musculature  at  these  points  is 
sphincteric  in  nature,  and,  except  during  the  pas- 
sage of  food,  the  lumen  in  these  parts  is  closed. 
The  diameter  at  each  of  these  points  is  a  little  over 
J  an  inch  (14  mm.)  ;  the  diameter  elsewhere  is  about 
|  of   an   inch   (17   mm.   to  21   mm.).     By   forcible 


192  THE    HEAD    AND    NECK  [Chap. 

distension  the  two  upper  narrow  parts  could  be 
distended  to  a  diameter  of  18  to  19  mm.,  the  lower 
part  to  25  mm.,  and  the  rest  of  the  gullet  to  a 
diameter  of  nearly  lj  inches  (35  mm.).  It  follows 
that  foreign  bodies  when  swallowed  are  most  apt 
to  lodge  either  at  the  commencement  of  the  gullet 
or  at  the  spot  where  it  passes  through  the  dia- 
phragm. The  same  parts  also  are  those  most  apt 
to  show  the  effects  of  corrosives  that  have  been 
swallowed. 

Among  the  relations  of  the  oesophagus,  the 
following  may  be  noted  as  receiving  illustration 
in  surgical  practice  :  The  gullet  is  in  nearly  all 
its  course  in  close  relation  with  the  front  of 
the  vertebral  column.  In  the  neck  the  trachea 
is  immediately  in  front  of  it.  In  the  thorax 
it  has  the  left  bronchus,  left  bronchial  glands, 
pericardium,  and  left  auricle  in  front  of  it,  while 
the  two  vagi  form  a  plexus  on  it.  The  left 
bronchial  glands,  when  enlarged,  may  press  on  the 
gullet,  adhere  to  it,  or  even  cause  localized  soften- 
ing and  diverticula  to  spring  from  it.  The 
thoracic  duct  passes  behind  to  reach  the  left  side 
of  the  gullet  in  the  upper  part  of  the  thorax, 
while  in  the  lower  part  the  aorta,  at  first  to  the 
left  of  the  oesophagus,  gradually  becomes  pos- 
terior to  it.  It  is,  moreover,  partly  in  contact 
with  both  pleurae,  but  more  especially  with  the 
membrane  of  the  right  side ;  and,  lastly,  the  recur- 
rent laryngeal  nerve  ascends  between  it  and  the 
trachea.     (See  Figs.  50  and  90,  pp.  228  and  435.) 

Foreign  bodies  impacted  in  the  gullet  are  very 
apt  to  lead  to  ulcerations  that  may  open  ad- 
jacent parts.  Thus,  in  the  Musee  Dupuytren  is 
a  specimen  showing  a  five-franc  piece  which  had 
stuck  in  the  gullet,  and  had  produced  an  ulcer 
that  had  opened  the  aorta.  In  another  instance 
a  "  smasher  "  swallowed  a  counterfeit  half-crown 
piece.  Eight  months  afterwards  he  died  of 
haemorrhage.  The  coin  had  sloughed  into  his 
aorta.  In  another  case  (Lancet,  1871),  a  fish-bone, 
lodged   in   the  gullet  opposite  the   fourth   dorsal 


IX]  (ESOPHAGEAL    MALFORMATIONS  193 

vertebra,  had  caused  two  perforating  ulcers;  one 
on  the  right  side  had  caused  plugging  of  the  vena 
azygos  major,  while  the  other  on  the  left  had  made 
a  hole  in  the  aorta.  Less  frequently,  impacted 
foreign  substances  have  found  their  way  into  the 
trachea  and  into  the  posterior  mediastinum.  Dr. 
Ogle  reports  a  case  {Path.  Soc.  Trans. ,  vol.  iv.) 
where  a  piece  of  bone  impacted  in  the  gullet 
induced  ulceration  of  an  intervertebral  disc  and 
subsequent  disease  of  the  spinal  cord.  Carcinoma 
of  the  gullet,  also,  when  it  spreads,  is  apt  to 
invade  adjacent  parts,  and  especially  to  open  into 
the  trachea  or  bronchi.  If  it  spreads  to  the 
pleura,  it  will  usually  involve  the  right  pleura, 
as  being  the  membrane  more  in  relation  with  the 
gullet.  Cancer  of  the  gullet  has  so  spread  as  to 
invade  the  thyroid  body,  the  pericardium,  and 
the  lung,  and  has  opened  up  the  first  intercostal 
artery  in  one  case  and  the  right  subclavian  in 
another  (Butlin's  4i  Sarcoma  and  Carcinoma," 
1882). 

The  sensory  nerve  supply  of  the  oesophagus 
comes  mainly  from  the  fifth  dorsal  segment  of  the 
cord  (Head).  In  cases  of  cancer  or  burns  of  the 
gullet,  pain  is  referred  to  the  skin  of  this  seg- 
ment (see  Fig.   70,  p.  345). 

(Esophageal  malformations. — In  the  newly  born 
the  upper  part  of  the  oesophagus  may  end  blindly, 
while  the  lower  part  commences  by  an  opening 
in  or  near  the  bifurcation  of  the  trachea,  so 
that  milk  can  only  reach  the  stomach  by  first 
passing  into  the  larynx  and  trachea.  Death  soon 
follows  from  suffocation  or  septic  pneumonia. 
The  condition  is  the  result  of  a  maldevelopment 
of  the  septum  between  the  trachea  and  oesophagus. 
Hernial  diverticula  of  the  mucous  membrane 
occasionally  occur  at  the  junction  of  the  oesopha- 
gus and  pharynx,  immediately  above  the  upper 
sphincter  of  the  oesophagus.  They  are  named 
pharyngeal  pouches,  and  protrude  between  the 
lower  border  of  the  inferior  constrictor  and 
commencement    of    the    oesophageal    musculature, 

H 


194  THE    HEAD    AND    NECK  [Chap. 

opposite  the  cricoid  cartilage.  Since  the  pouch 
lies  against  the  spine,  it  necessarily  compresses  the 
commencement  of  the  oesophagus  when  it  becomes 
filled  with  food. 

The  operation  of  oesophagotomy  consists  in 
incising  the  gullet  for  the  purpose  of  removing 
an  impacted  foreign  body.  The  gullet  is  usually 
reached  from  the  left  side,  since  it  projects  more 
on  that  aspect.  The  incision  is  made  between  the 
sterno-mastoid  and  the  trachea,  in  the  same  direc- 
tion as  the  incision  for  ligaturing  the  common 
carotid.  The  cut  extends  from  the  top  of  the 
thyroid  cartilage  to  the  sterno-clavicular  joint. 
The  omo-hyoid  muscle  is  drawn  outwards,  or  cut. 
The  great  vessels,  larynx,  and  thyroid  gland  are 
drawn  aside,  and  care  must  be  taken  not  to  wound 
these  structures  nor  damage  the  thyroid  vessels, 
thoracic  duct,  or  the  recurrent  nerve.  The  gullet, 
when  exposed,  is  opened  by  a  vertical  incision. 

Oreat  vessels. — The  course,  relations,  and 
abnormalities  of  the  great  cervical  vessels,  to- 
gether with  the  operations  whereby  they  may  be 
ligatured,  and  the  details  pertaining  to  those 
procedures,  are  so  fully  given,  not  only  in  works 
on  operative  surgery,  but  also  in  the  chief  ana- 
tomical text-books,  that  nothing  need  be  said  upon 
the  matter  in  this  place.  The  main  relationships 
of. the  carotid  and  subclavian  arteries  are  shown 
in  Fig.  39,  p.  168.  In  Brasdor's  operation  a  main 
trunk  is  ligatured  on  the  distal  side  of  an 
aneurysm,  not  branches  intervening  between  the 
sac  and  the  ligature.  The  cure  by  this  measure 
depends  upon  the  fact  that  blood  does  not  con- 
tinue to  go  to  parts  when  once  the  need  for  blood 
in  them  is  diminished.  Thus,  after  amputation 
at  the  hip-joint,  the  femoral  artery,  having  no 
need  to  carry  to  the  stump  the  amount  of  blood 
it  brought  to  the  limb,  often  shrinks  to  a  vessel 
no  larger  than  the  radial.  Wnen  an  aneurysm  low 
down  in  the  carotid  artery  is  treated  by  ligature 
of  the  vessel  near  its  bifurcation  by  Brasdor's 
method,   the   blood,    having   now,    as   it  were,    no 


IX]  VESSELS    OF    THE    NECK  195 

object  in  entering  the  carotid  trunk,  soon  ceases 
to  fill  the  vessel  entirely,  and  the  artery  (and  in 
successful  cases  the  aneurysm)  shrinks  in  con- 
sequence. The  right  carotid  and  subclavian  have 
also  been  ligatured  for  aortic  aneurysm  with  some 
success,  and  here  also  the  reason  for  the  good 
effected  by  the  operation  is  difficult  to  appreciate. 
It  has  been  pointed  out  that  the  innominate  artery 
lies  more  or  less  directly  in  the  axis  of  the  ascend- 
ing aorta,  while  the  left  carotid  and  subclavian 
arteries  arise  at  an  angle  to  that  axis,  and  it  is 
upon  this  fact  that  reasons  have  been  founded  for 
selecting  the  vessels  of  the  right  side  (Barwell). 
The  matter  is,  however,  complicated  by  the  know- 
ledge that  when  vegetations  are  swept  off  the 
aortic  valves  they  enter  the  left  carotid  with  in- 
finitely greater  frequency  than  they  do  the  right. 
The  whole  subject,  indeed,  requires  investigation. 

The  cervical  connective  tissue  being  lax,  aneu- 
rysms in  this  part  can  grow  and  spread  rapidly, 
and  usually  soon  produce  "  pressure  symptoms." 
As  examples  of  these  may  be  noted  oedema  and 
lividity  of  the  face  and  of  the  upper  limb  from 
pressure  upon  the  main  veins,  laryngeal  symptoms 
from  pressure  upon  the  recurrent  nerve  or  trachea, 
spasm  of  the  diaphragm  from  pressure  upon  the 
phrenic  nerve,  damage  to  the  sympathetic,  and 
giddiness  and  impaired  vision  from  anaemia  of 
the  brain. 

The  vertebral  artery  has  been  ligatured  with 
doubtful  benefit  in  cases  of  epilepsy.  It  is  sur- 
rounded by  vasomotor  nerves  derived  from  the 
inferior  cervical  ganglion,  which  also  are  neces- 
sarily tied.  The  artery  is  reached  through  an  in- 
cision made  along  the  posterior  border  of  the 
sterno-mastoid  muscle  just  above  the  clavicle.  The 
" carotid  tubercle"  (see  Fig.  39,  p.  168)  is  then 
sought  for,  and  vertically  below  it  lies  the  artery, 
in  the  gap^  between  the  scalenus  anticus  and 
longus  colli  muscles.  The  procedure  is  sur- 
rounded with  considerable  difficulties. 

Air  in  veins,— The  veins  of  the  neck  are  under 


196  THE    HEAD    AND    NECK  [Chap. 

the  influence  of  the  respiratory  movements.  The 
veins  do  not  collapse  owing  to  attachments  to 
the  surrounding  fascise.  During  inspiration  these 
vessels  become  more  or  less  emptied ;  during  ex- 
piration they  become  enlarged  and  turgid.  ^  With 
greatly  impeded  breathing  they  may  attain  for- 
midable size.  Since  ether  usually  causes  some 
respiratory  difficulty,  it  is  seldom  administered 
in  operations  on  the  neck.  The  only  other  veins 
that  are  under  the  influence  of  the  aspiratory 
power  of  the  thorax  are  the  axillary  vein  and 
its  larger  tributaries.  When  any  one  of  these 
vessels  is  wounded,  and  the  wound  is  for  the 
moment  dry,  air  may  very  readily  be  drawn  into 
it  during  the  inspiratory  act,  just  as  air  is  drawn 
into  the  trachea.  The  air  causes  embolism  of  the 
pulmonary   capillaries. 

Valves  in  the  veins  of  the  neck. — The  subclavian 
veins  and  their  tributaries  are  liberally  pro- 
vided with  valves,  but  the  internal  jugular  has 
only  one  pair,  situated  at  its  termination  in 
the  innominate  vein.  There  are  no  valves  in  the 
innominate  veins  or  in  the  superior  vena  cava. 
When  the  venous  pressure  within  the  thorax  is 
greatly  raised,  as  in  lifting  heavy  weights,  only 
the  terminal  valves  of  the  internal  jugular  vein 
prevent  the  transmission  of  the  pressure  to  the 
brain.  In  accidents  which  cause  sudden  compres- 
sion of  the  thorax,  the  head  and  neck  may  remain 
livid  for  days  following  the  accident.  The 
lividity  is  probably  due  to  the  jugular  valves 
yielding,  thus  subjecting  the  capillaries  of  the 
head  and  neck  to  a  higher  pressure  than  they  are 
able  to  withstand. 

The  lymphatic  glands  of  the  head  and 
neck  are  numerous,  and  arranged  in  the  follow- 
ing sets   (Fig.    44)  : — 

(1)  Submaxillary  glands,  10  to  15  in  number, 
situated  at  the  lower  border  of  the  jaw  beneath 
the  cervical  fascia ;  (2)  the  suprahyoid,  1  or  2 
in  number,  situated  between  the  chin  and  hyoid 
bone  near  the  middle  line;   (3)   parotid  or  pre- 


IX 


LYMPHATIC    GLANDS 


■197 


Fig.  44. — Showing  the  position  of  the  lymphatic  glands  of 
the  head  and  neck.  The  outlines  of  the  sterno- 
mastoid  (S.M.),  trapezius  (TR.),  internal  jugular, 
subclavian,  and  right  innominate  veins  are  shown. 

1,  Submaxillary  glands,  1'  area  drained  ;  2,  suprahyoid  glands, 2'  area 
drained  :  3,  parotid  glands,  3'  area  drained  ;  4,  postauricular 
glands,  4'  area  drained  ;  5,  occipital  glands,  5'  area  drained  ;  6,  in 
front  of  external  jugular  vein,  marking  position  of  the  superficial 
cervical  glands  ;  7,  laryngeal  gland  ;  8,  8,  8,  upper  deep  cervical 
glands  ;  9,  9,  9,  lower  deep  cervical  glands  ;  10,  gland  receiving 
lymph  from  thyroid  ;  11,  superior  mediastinal  glands  j  12,  axillary 
glands. 


198  THE    HEAD    AND    NECK  LChap. 

auricular  set,  situated  in  and  over  the  parotid 
gland;  (4)  postauricular  or  mastoid,  2  to  4  in 
number,  situated  over  the  mastoid  process;  (5) 
occipital,  3  to  5  in  number,  over  the  insertion 
of  the  complexus  muscle;  (6)  superficial  cervical 
glands,  often  absent,  situated  over  the  sterno- 
mastoid  along  the  external  jugular  vein;  (7) 
laryngeal,  1  to  3  in  number,  below  the  great 
horn  of  the  hyoid ;  (8)  the  upper  deep  cervical  set, 
10  to  20  in  number,  situated  over  the  upper  part 
of  the  internal  jugular  vein  and  bifurcation  of  the 
common  carotid  artery ;  (9)  lower  deep  cervical 
set,  surrounding  the  terminal  parts  of  the  in- 
ternal jugular,  subclavian,  external  jugular,  and 
transverse  cervical  veins.  This  set  becomes  con- 
tinuous with  the  axillary  and  mediastinal  glands. 

These  glands  are  very  often  enlarged  and  in- 
flamed, and  it  is  in  this  part  of  the  lymphatic 
system  that  the  changes  in  scrofula  are  most  com- 
monly met  with.  The  inflammatory  affections  in 
glands  would  appear  to  be  always  of  a  secondary 
nature  (if  we  exclude  some  cases  of  inflammation 
incited  by  injury,  and  perhaps  by  exposure  to 
severe  cold),  and  to  follow  disturbances  in  those 
parts  of  the  periphery  whence  they  respectively 
receive  their  lymph.  It  may  be  convenient,  there- 
fore, to  group  the  relations  of  certain  glands  to 
certain  parts  of  the  periphery. 

Scalp. — Posterior  part  =  occipital  and  post- 
auricular  glands.  Frontal  and  parietal  portions 
=    parotid  glands  (Fig.   44). 

Vessels  from  the  scalp  also  enter  the  super- 
ficial cervical  set  of  glands. 

Skin  of  face  and  neck  =  submaxillary,  parotid, 
and   superficial   cervical   glands. 

External  ear   =   superficial  cervical  glands. 

Lotver  lip  =  submaxillary  and  suprahyoid 
glands. 

Buccal  cavity  =  submaxillary  glands  and  deep 
cervical  glands  (upper  set). 

Gums  of  lower  jaw  =  submaxillary  glands. 

Tongue. — Anterior  portion    =  suprahyoid  and 


IX]  LYMPH-GLANDS  109 

submaxillary  glands.     Posterior  portion    =    deep 
cervical  glands  (upper  set). 

Tonsils  and  palate  =  deep  cervical  glands 
(upper  set). 

Pharynx. — Upper  part  =  parotid  and  retro- 
pharyngeal glands.  Lower  part  =  deep  cervical 
glands   (upper  set). 

Larynx,  orbit,  and  roof  of  mouth  =  deep  cer- 
vical glands  (upper  set). 

Nasal  fossce  =  retropharyngeal  glands,  deep 
cervical  glands  (upper  set).  Some  lymphatics 
from  the  posterior  part  of  the  fossae  enter  the 
parotid  glands.* 

In  the  removal  of  the  deep  cervical  glands 
a  number  of  structures  are  liable  to  be  wounded. 
The  glands  frequently  become  firmly  adherent  to 
the  internal  jugular  vein;  the  uppermost  glands 
surround  the  spinal  accessory  nerve;  the  super- 
ficial cervical  nerves  pass  among  those  of  the 
lower  deep  cervical  set ;  the  thoracic  duct  has  been 
wounded  in  removing  glands  from  the  left  supra- 
clavicular fossa. 

Thoracic  duct  in  the  neck. — A  point  taken 
on  the  upper  border  of  the  clavicle,  1  inch  from 
its  sternal  end,  will  mark  the  angle  between  the 
internal  jugular  and  subclavian  veins  at  or  near 
which  the  thoracic  duct  ends.  In  forty  bodies 
investigated  by  Messrs.  F.  G.  Parsons  and  P.  W.  G. 
Sargent  the  duct  was  found  to  end  in  the  ter- 
minal part  of  the  internal  jugular  vein  in  thirty- 
five  instances ;  in  nearly  half  of  these  cases  the 
terminal  part  of  the  duct  divided;  it  frequently 
has  two  orifices,  and  may  have  as  many  as  four. 
At  its  termination  the  duct  curves  outwards  over 
the  scalenus  anticus  and  phrenic  nerve  above  its 
point  of  entrance  where  it  is  usually  furnished 
with  valves.  Ligature  of  the  duct  is  followed 
by  no  untoward  symptoms,  as  a  rule,  a  result 
which  is  due  to  the  free  anastomosis  which  exists 
between  it  and  the  lymphatics  of  the  right  side 

*  From  "Scrofula,  and  its  Gland  Diseases,"  by  the  Author. 


200  THE    HEAD    AND    NECK  [Chap 

of  the  thorax  and  to  communications  with  the 
azygos  veins  (Leaf).  As  the  duct  ascends  behind 
the  left  common  carotid  and  subclavian  arteries 
to  enter  the  neck,  it  lies  in  contact  with  the 
pleura  and  lung.  On  the  rigbt  side  the  thoracic 
duct  is  represented  by  the  right  lymphatic  trunk. 
The  tributaries  of  these  two  main  lymphatic 
channels  are  in  free  communication  within  the 
thorax. 

Branchial  fistula*. — Certain  congenital  fis- 
tulae  are  sometimes  met  with  in  the  neck,  which 
are  due  to  partial  persistence  of  one  of  the 
branchial  clefts.  These  clefts  are  placed  in  the 
foetus  between  the  branchial  arches.  The  arches 
are  usually  described  as  five  in  number.  The 
first  lays  the  foundation  for  the  lower  jaw  and 
malleus.  From  the  second  are  developed  the  sty- 
loid process,  the  stylo-hyoid  ligament,  and  lesser 
cornu  of  the  hyoid  bone.  From  the  third  are 
formed  the  body  and  greater  cornu  of  the  hyoid 
bone,  while  the  fourth  and  fifth  take  part  in  the 
formation  of  the  soft  parts  of  the  neck  below  the 
hyoid  bone.  The  first  cleft  is  between  the  first 
and  second  arches.  "The  cervical  branchial  fistulse 
appear  as  very  fine  canals  opening  into  minute 
orifices  in  one  or  both  sides  of  the  fore  part  of 
the  neck  and  leading  backwards  and  inwards  or 
backwards  and  upwards  towards  the  pharynx  or 
oesophagus  "  (Paget).  Their  length  is  about  lj  to 
2j  inches,  and  their  diameter  varies  from  that  of 
a  bristle  to  that  of  an  ordinary  probe.  The 
orifice  of  a  cervical  fistula  is  usually  situated 
just  above  the  sterno-clavicular  joint  (Fig.  45), 
and  represents  the  orifice  of  the  cervical  sinus, 
a  depression  or  pocket  formed  during  the  develop- 
ment of  the  neck  of  the  foetus,  and  serving  as  a 
common  orifice  for  the  visceral  clefts  in  which  the 
tonsil,  thymus  and  lateral  thyroids  are  developed 
(Fie:.  45).  The  fistula  passes  towards  the  bifur- 
cation of  the^  common  carotid,  where  it  may  come 
into  communication  with  the  carotid  bodv  (derived 
from  the  third  cleft),  or  with  the  tonsillar  recess 


IX] 


BEANCHIA"L    FISTULiE 


201 


(from  the  second  cleft).  It  can  be  understood 
that  only  parts  of  these  saccular  structures  and 
outgrowths  may  persist,  such  remnants  forming 
the  basis  for  cervical  cysts.    Certain  dermoid  cysts 


Fig.  45. — Diagram  to  show  the  position  and  connexions 
of  various  embryological  remnants  in  the  neck.  (Br. 
S.  J.  A.  Beale.) 

A,  Tonsil ;  B,  remnant  of  tonsillar  sac  (from  second  cleft  recess)  ;  C, 
carotid  body  between  external  and  internal  carotid  arteries ; 
D,  stalk  of  thymus  (3rd  cleft)  ;  e,  cervical  sinus  (united  with 
2nd  cleft  recess  on  left  side)  ;  F,  cervical  thymus  ;  G,  common 
carotid,  G'  median  part  of  thyroid  and  thyro-glossal  duct ; 
H,  infrahyoid  part  of  median  thyroid  ;  I,  stalk  of  lateral  thyroid 
from  4th  cleft ;  K  K,  thymus  in  thorax, 


202  THE    HEAD    AND    NECK  [Chap.  IX 

of  the  neck,  and  also  certain  polycystic  congenital 
tumours,  occurring  as  one  form  of  "  hydrocele 
of  the  neck,"  also  arise  from  these  branchial 
remnants.  At  the  orifice  of  the  fistulse,  or  at  the 
position  where  they  usually  occur,  tags  of  skin 
containing  cartilage  may  appear.  They  are  termed 
supernumerary  auricles,  because  they  occupy  the 
same  relationship  to  the  fistulse  that  the  external 
ear  does  to  the  first  visceral  cleft.# 

The  ventricle  of  the  larynx,  as  is  normally  the 
case  in  many  apes,  may  become  prolonged  into  a 
sac  which  passes  into  the  neck  through  the  thyro- 
hyoid membrane,  thus  forming  a  cervical  air 
cyst  or  sac. 


Part  IL— THE    THORAX 

CHAPTER  X 
THE  CHEST  AND  ITS  VISCERA 

The  Thoracic  Walls 

The  two  sides  of  the  chest  are  seldom  sym- 
metrical, the  circumference  of  the  right  side  being 
usually  the  greater,  a  fact  that  is  supposed  to 
be  explained  by  the  unequal  use  of  the  upper 
limbs.  In  Pott's  disease,  involving  the  dorsal 
region,  when  the  spine  is  much  bent  forwards 
the  thorax  becomes  greatly  deformed.  Its  antero- 
posterior diameter  is  increased,  the  sternum 
protrudes,  and  may  even  be  bent  by  the  bending 
of  the  spine,  the  ribs  are  crushed  together,  and 
the  body  may  be  so  shortened  that  the  lower 
ribs  overlap   the  iliac  crest. 

In  pigeon  breast  deformity  the  sternum  and 
cartilages  are  rendered  protuberant,  so  that  the 
antero-posterior  measurement  of  the  chest  is  much 
increased,  while  a  deep  sulcus  exists  on  either 
side  along  the  line  of  junction  of  the  ribs  and 
their  cartilages.  It  is  by  the  sinking-in  of  the 
parietes  along  the  costo-chondral  junctions  that 
the  protuberance  is  produced.  In  children,  and 
especially  in  rickety  children,  the  thorax  is  very 
pliable  and  elastic,  and  if  a  constant  impediment 
exists  to  the  entrance  of  air,  as  afforded,  for 
203 


204  THE    THORAX  [Chap. 

example,  by  greatly  enlarged  tonsils,  the  thoracic 
walls  may  yield  in  time  to  the  suction  brought 
to  bear  upon  them  at  each^  inspiration.  The 
weakest  part  of  the  thorax  is  along  the  costo- 
chondral  line  on  either  side,  and  it  is  here  that 
the  parietes  yield  most  conspicuously  in  such 
cases,  and  by  this  yielding  the  deformity  is  pro- 
duced. 

Deformities  of  the  ehest  result  from  abnor- 
mal curvatures  of  the  dorsal  part  of  the  spinal 
column.  The  ribs  are  firmly  bound  to  the  verte- 
brae by  the  costo-vertebral  and  costo-transverse 
ligaments,  and  hence  alteration  in  the  position  of 
vertebrae  is  attended  by^  changes  in  the  costal 
series.  Thus,  when  there  is  kyphosis  in  the  dorsal 
region  the  upper  part  of  the  spine  is  bent  for- 
wards and  downwards,  carrying  with  it  the 
upper  ribs  and  the  sternum.  The  antero-posterior 
diameter  of  the  thorax  is  thereby  increased,  but 
its  vertical  and  transverse  measurements  are  de- 
creased. When  lateral  curvature  is  produced  in 
the  dorsal  region,  the  ribs,  on  the  side  towards 
which  the  bend  occurs,  are  necessarily  compressed, 
while  on  the  opposite  side  they  are  separated.  In 
scoliosis  of  the  spine  not  only  is  a  lateral  curva- 
ture formed,  but  the  vertebrae  undergo  a  rotation 
at  the  same  time.  The  vertebral  bodies  move  to- 
wards the  convexity  and  their  spines  towards  the 
concavity  of  the  curvature  (Fig.  46).  The  ribs  on 
the  concave  side  are  carried  forwards  on  the  traps- 
verse  processes  and  their  angles  open  out,  the  side 
of  the  chest  becoming  flattened  behind.  On  the 
other  side  (convex)  the  angles  are  unduly  promi- 
nent, for  the  ribs  are  carried  backwards  at  their 
vertebral  extremities  and  bent  inwards  in  front. 
The  transverse  diameter  of  the  chest  thus  becomes 
oblique  (Fig.  46).  On  the  concave  side  the  inter- 
costal spaces  are  diminished  in  size,  the  ribs  even 
coming  into  contact,  while  on  the  convex  side 
the  spaces  are  increased  in  size.  The  thoracic 
viscera  are  necessarily  distorted  in  shape  and 
altered  in  position, 


X]  FRACTURES    OF    THE    STERNUM  205 

The  sternum.— -The  upper  edge  of  the  sternum 
corresponds  to  the  disc  between  the  second  and 
third  dorsal  vertebrae,  and  the  ster no-xiphoid 
joint  to  the  middle  of  the  tenth  dorsal.  In  the 
foetus  at  full  term  the  upper  edge  of  the  sternum 
is  opposite  the  middle  of  the  first  dorsal  vertebra 
(Symington).  A  transverse  ridge  may  be  felt 
upon  its  anterior  surface  that  corresponds  to  the 
junction  of  the  manubrium  and  gladiolus,  and  is 
in  a  line  with 
the  second  costal 
cartilages.  The 
skin  over  the 
sternal  region  is 
the  part  of  the 
surface  most  fre- 
quently the  seat 
of  cheloid.  The 
bone  is  rarely 
fractured,  being  Fig.  46.- Showing  the  changes  in  the 
sort  ana  spongy,  thorax  which  f0now  scoliosis  of 
and  supported  by  the  spIne.  (After  Retard.) 
the    elastic    ribs  mw  ,  ,,        .    . 

j   fi     •      „QT..|.ii  Tne  convexity  of  the  spinal  curvature  is 

cinu  tneir   cartll-  towards  the  right ;  on  that  side  the  ribs 

ages,      as      by      a  are  sharply  bent  at  their  angles.    On  the 

series  of  springs  concave  (left)  side  the  ribs  have  an  open 

In  the  old,  when 

the  cartilages  are  ossified  and  the  chest  is  more 
rigid,  the  tendency  to  fracture  is  increased.  The 
sternum  is  most  often  found  fractured  in  connexion 
with  injuries  to  the  spine,  although  it  may  be 
broken  by  simple  direct  violence.  The  bone  may 
be  fractured  by  violent  bending  of  the  spine  back- 
wards, and  by  abrupt  bending  of  it  forwards.  In 
the  former  instance  the  lesion  is  probably  due  to 
muscular  violence,  to  the  abdominal  muscles  and 
the  sterno-mastoid  pulling  one  against  the  other. 
In  the  latter  instance  the  lesion  is  commonly 
brought  about  by  the  violent  contact  of  the  chin 
with  the  bone.  Dislocation  may  occur  at  the 
sterno-manubrial  joint.  The  manubrium  in  these 
injuries    generally    remains    in    situ,    while    the 


206  THE    THOHAX  Chap. 

gladiolus  with  the  ribs  is  displaced  forwards  in 
front  of  it.  A  considerable  degree  of  respiratory 
movement  takes  place  at  this  joint;  only  in  very 
old  people  does  it  become  obliterated  by  bony 
union.  It  possesses  a  distinct  synovial  cavity 
surrounded  by  strong  fibrous  and  fibro-cartilagin- 
ous  ligaments.  Malgaigne  cites  the  case  of  a 
youth  who,  from  constant  bending  at  his  work  as 
a  watchmaker,  caused  the  second  piece  of  the 
sternum  to  glide  backwards  behind  the  manu- 
brium. 

From  its  exposed  position  and  cancellous  struc- 
ture, the  sternum  is  liable  to  many  affections,  such 
as  caries  and  gummatous  periostitis.  The  com- 
parative softness  also  of  the  bone  is  such  that 
it  has  been  penetrated  by  a  knife  in  homicidal 
wounds.  The  shape  and  position  of  the  bone  have 
also  been  altered  by  pressure,  as  seen  sometimes 
in  artisans  following  employments  requiring  in- 
struments, etc.,  to  be  pressed  against  the  chest. 

Certain  holes  may  appear  in  the  middle  of  the 
sternum,  and  through  them  mediastinal  abscesses 
may  escape,  and  surface  abscesses  pass  deeply  into 
the  thorax.  These  holes  result  from  imperfect 
union  of  the  right  and  left  sternal  bars,  out  of 
which  the  sternum  is  formed.  In  the  case  of  E. 
Groux,  the  bone  was  separated  vertically  into  two 
parts.  The  gap  could  be  opened  by  muscular 
effort  and  the  heart  exposed,  covered  only  by  the 
soft  parts.  The  sternum  has  been  trephined  for 
mediastinal  abscess,  and  for  paracentesis  in  peri- 
cardial effusion,  and  it  has  been  proposed  also  to 
ligature  the  innominate  artery  through  a  trephine 
hole  in  the  upper  part  of  the  bone. 

The  ribs  are  placed  so  obliquely  that  the  an- 
terior end  of  one  rib  is  on  a  level  with  the  pos- 
terior end  of  a  rib  some  way  below  it  in  numerical 
order.  Thus  the  second  rib  in  front  corresponds 
to  the  fifth  rib  behind,  and  the  insertion  of  the 
seventh  to  the  tenth.  If  a  horizontal  line  be 
drawn  round  the  body  at  the  level  of  the  inferior 
angle  of  the  scapula,   while  the  arms  are  at  the 


X]  THE    RIBS  207 

side,  the  line  would  cut  the  sternum  in  front  at 
the  attachment  of  the  sixth  cartilage,  would  cut 
the  fifth  rib  at  the  nipple  line,  and  the  ninth  rib 
at  the  vertebral  column.  The  second  rib  is  indi- 
cated by  the  transverse  ridge  on  the  sternum 
already  alluded  to  (angulus  Ludovici).  The  lower 
border  of  the  pectoralis  major  leads  to  the  fifth 
rib,  and  the  first  visible  serration  of  the  serratus 
magnus  corresponds  to  the  sixth.  The  longest  rib 
is  the  seventh,  the  shortest  the  first.  The  most 
oblique  rib  is  the  ninth. 

The  ribs  are  elastic  and  much  curved,  and, 
being  attached  by  many  ligaments  behind  to  the 
column,  and  in  front  to  the  yielding  cartilages, 
resist  injuries  tending  to  produce  fracture  with 
the  qualities  possessed  by  a  spring.  A  rib  may 
be  fractured  by  indirect  violence,  as  by  a  wheel 
passing  over  the  body  when  lying  prostrate  on  the 
back.  In  such  a  case  the  force  tends  to  approxi- 
mate the  two  ends  of  the  bone,  and  to  increase  its 
curve.  When  it  breaks,  therefore,  it  breaks  at 
the  summit  of  its  principal  curve,  i.e.  about  the 
centre  of  the  bone.  The  fragments  fracture  out- 
wards, and  the  pleura  stands  no  risk  of  being 
penetrated.  When  the  rib  is  broken  by  direct 
violence,  lesion  occurs  at  the  spot  encountered  by 
the  force,  the  bone  fractures  inwards,  the  curve 
of  the  rib  tends  to  be  diminished  rather  than 
increased,  and  there  is  much  risk  of  the  fragments 
lacerating  the  pleura. 

Those  most  often  broken  are  the  sixth,  seventh, 
and  eighth,  they  being  under  ordinary  circum- 
stances the  most  exposed.  The  rib  least  frequently 
fractured  is  the  first,  which  lies  under  cover  of  the 
clavicle.  In  elderly  people  dying  from  phthisis  the 
cartilage  of  the  first  rib  is  often  found  to  be  cal- 
cified and  occasionally  to  be  fractured.  Fractures 
are  more  common  in  the  elderly  than  in  children, 
owing  to  the  ossification  of  the  cartilages  that 
takes  place  in  advancing  life.  When  a  rib  is 
fractured,  no  shortening  occurs,  the  bone  being 
fixed   both    in    front    and   behind,    while    vertical 


208  THE    THORAX  [Chap. 

displacement  is  prevented  by  the  attachments  of 
the  intercostal  muscles.  Thus  no  obvious  de- 
formity is  produced  unless  a  number  of  consecu- 
tive ribs  are  the  subjects  of  fracture.  These  bones 
have  been  broken  by  muscular  violence,  as  during 
coughing,  and  in  violent  expulsive  efforts  such  as 
are  incident  to  labour.  In  such  instances  the  ribs 
are  probably  weakened  by  atrophy  or  disease. 

In  rickets  changes  take  place  at  the  point  of 
junction  of  the  ribs  and  cartilages  leading  to 
bony  elevations,  which  produce,  when  the  ribs  on 
both  sides  are  affected,  the  condition  known  as  the 
-?  rickety  rosary." 

The  intercostal  spaces  are  wider  in  front 
than  behind,  and  between  the  upper  than  the 
lower  ribs.  The  widest  of  the  spaces  is  the  third, 
then  the  second,  then  the  first.  The  seventh, 
eighth,  ninth,  and  tenth  interspaces  are  very  nar- 
row in  front  of  the  angles  of  the  ribs.  The  first 
five  spaces  are  wide  enough  to  admit  the  whole 
breadth  of  the  index  finger.  The  spaces  are 
widened  in  inspiration,  narrowed  in  expiration, 
and  can  be  increased  in  width  by  bending  the  body 
over  to  the  opposite  side. 

Paracentesis  is  usually  performed  in  the  sixth 
or  seventh  space,  at  a  point  #  midway  between 
the  sternum  and  the  spine,  or  midway  between  the 
anterior  and  posterior  axillary  lines.  The  seventh 
space  can  be  readily  identified  by  its  relation- 
ship to  the  angle  of  the  scapula;  when  the  arm  is 
by  the  side  of  the  body  this  space  is  slightly  over- 
lapped by  the  angle.  If  a  lower  space  be  selected 
there  is  danger  of  wounding  the  diaphragm, 
especially  upon  the  right  side.  ^  If  the  eighth  or 
ninth  space  be  selected  the  incision  is  made  just 
externally  to  the  line  of  the  angle  of  the  scapula. 
The  trocar  should  be  entered  during  inspiration, 
the  space  being  widened  thereby,  and  should  be 
kept  as  near  as  possible  to  the  lower  border  of  the 
space,  so  as  to  avoid  the  intercostal  vessels.  Tap- 
ping of  the  chest  through  any  space  posterior  to 
the   angles  of  the   ribs  is  not   practicable,   owing 


X]  .     PARACENTESIS  209 

to  the  thick  covering  of  muscles  upon  the  thoracic 
wall  in  this  place,  and  the  fact  that  the  inter- 
costal artery,  having  a  more  horizontal  course 
than  the  corresponding  ribs,  crosses  the  middle 
of  this  part  of  the  space  obliquely.  Beyond  the 
angle  the  intercostal  vessels  lie  in  a  groove  on 
the  inferior  border  of  the  rib  forming  the  upper 
boundary  of  the  space.  The  vein  lies  immediately 
above  the  artery,  and  the  nerve  immediately  below 
it.  In  the  upper  four  or  five  spaces,  however,  the 
nerve  is  at  first  higher  than  the  artery.  Paracen- 
tesis of  the  thorax  is  occasionally  followed  by  syn- 
cope or  even  death.  It  is  difficult  to  account  for 
such  a  result;  it  may  be  a  reflex  inhibition  of  the 
heart  set  up  during  perforation  of  the  parietal 
pleura,  which  is  richly  supplied  by  the  intercostal 
nerves,  or  by  injury  to  the  lung,  which  is  supplied 
by  the  vagus. 

Pus  may  readily  be  conducted  along  the  loose 
tissue  between  the  two  layers  of  intercostal  mus- 
cles. Thus,  in  suppuration  following  upon  disease 
of  the  vertebrae,  or  of  the  posterior  parts  of  the 
ribs,  the  pus  may  be  conducted  along  the  inter- 
costal spaces  to  the  sternum,  and  may  thus  pre- 
sent at  a  considerable  distance  from  the  real  seat 
of  the  disease. 

Removal  of  ribs.— In  order  to  obtain  a  free 
opening  into  the  pleural  cavity  a  portion  of  one 
or  even  two  ribs  may  be  excised. 

In  some  cases  of  long-standing  empyema  with  an 
open  sinus,  all  that  part  of  the  bony  wall  of  the 
thorax  which  corresponds  to  the  outer  boundary 
of  the  suppurating  cavity  is  removed  in  order  that 
the  cavity  may  collapse  and  be  in  a  position  to 
close.  This  latter  measure  is  known  as  Estlander's 
operation,  or  thoracoplasty.  In  some  instances 
portions  of  as  many  as  nine  ribs  have  been  ex- 
cised, and  the  total  length  of  bone  removed  has 
reached  50  to  60  inches. 

In  removing  a  rib  the  bone  is  entirely  bared 
of  periosteum  with  the  rugine,  and  the  excision 
is  extraperiosteal.      In   this    way    the   intercostal 


210  THE    THORAX  [Chap. 

vessels  are  not  exposed,  and,  if  divided  subse- 
quently, can  be  readily  secured  when  the  ribs 
are  out  of  the  way. 

The  internal  mammary  artery  runs  paral- 
lel to  the  border  of  the  sternum,  and  about  \  an 
inch  from  it.  It  may  give  rise  to  rapidly  fatal 
haemorrhage  if  wounded.  The  vessel  may  readily 
be  secured  in  the  first  three  intercostal  spaces,  and 
with  some  difficulty  in  the  fourth  or  fifth  space. 
It  is  most  easily  reached  through  the  second  space, 
and  cannot  be  secured  through  any  space  below 
the  fifth. 

The  female  breast  extends  from  the  second 
rib  above  to  the  sixth  below,  and  from  the  side  of 
the  sternum  to  the  midaxillary  line  (Stiles). 
In  cases  of  retained  lactation  the  twelve  to  fifteen 
irregular  lobes  which  make  up  the  body  of  the 
gland  can  be  felt  radiating  outwards  from  the 
nipple.  The  lactiferous  ducts,  which  correspond 
in  number  to  the  lobes,  open  at  the  apex  of  the 
nipple,  within  which  each  shows  a  dilatation  or 
ampulla.  Branching  processes  of  adjoining  lobes 
unite  and  enclose  spaces  within  the  body  of  the 
gland,  containing  connective  tissue  and  masses  of 
fat.  After  the  menopause,  when  the  glandular 
tissue  is  absorbed  in  great  part,  and  during  the 
resting  condition,  fat  forms  the  greater  part  of 
the  female  breast.  Besides  the  main  body  of  the 
gland,  Stiles  has  drawn  attention  to  numerous 
peripheral  processes  which  lie  in  the  surrounding 
connective   tissue 

Although  the  principal  part  of  the  breast  rests 
on  the  pectoralis  major,  quite  one-third  of  the 
gland  crosses  the  outer  border  and  rests  on  the 
serratus^  magnus  within  the  axilla.  It  also  covers 
the  origins  of  the  obliquus  abdominis  externus  and 
rectus  abdominis.  In  excision  or  inflammation 
of  the  breast  it  is  important  to  bind  the  arm  by 
the  side  to  keep  the  parts  from  being  disturbed 
by  the  pectoralis  major.  Peripheral  processes  of 
the  gland  and  many  of  its  deep  lymphatics  enter 
the    pectoral    sheath,    hence    the    removal    of    this 


XJ  THE    MAMMA  211 

structure  with  part,  or  even  all,  of  the  pectoral 
musculature  if  complete  extirpation  of  cancer  is 
to  be  assured.  The  loose  retromammary  tissue 
which  binds  the  mamma  loosely  to  the  pectoral 
sheath  may  be  the  seat  of  abscess,  or  sometimes  of 
a  bursal  cyst. 

The  nipple,  in  the  male  and  in  the  virgin 
female,  is  situated  on  the  fourth  intercostal  space, 
about  |  of  an  inch  from  the  junction  of  the  ribs 
with  their  cartilages ;  after  lactation  the  breast 
becomes  pendent,  and  the  nipple  no  longer  serves 
as  a  guide  to  the  intercostal  spaces.  The  nipple 
contains  erectile  and  muscular  tissue,  and  is 
richly  supplied  by  cutaneous  branches  of  the  third 
and  fourth  spinal  nerves.  The  skin  is  pigmented, 
thin  and  sensitive,  and  often  the  seat  of  painful 
fissures  and  excoriations.  In  painful  diseases  of 
the  breast,  tender  areas  occur  over  the  fourth  and 
fifth  spinal  segments  (Fig.   70,  p.  345)   (Head). 

The  breast  is  developed  by  a  solid  invagination 
of  epiblast  at  the  point  afterwards  marked  by 
the  nipple.  About  the  sixth  month  of  total  life 
the  primitive  mammary  bud  branches  out  in  all 
directions  within  the  subcutaneous  tissue.  Thus 
it  comes  about  that  the  subcutaneous  fascia  is  con- 
densed around  the  gland,  forming  its  capsule.  The 
retromammary  part  of  the  capsule  is  connected  at 
the  interlobular  spaces  with  the  superficial  layer, 
which  in  turn  is  fixed  to  the  skin  by  subcutaneous 
bands,  or  skin  ligaments. 

It  is  through  lymph  channels  that  cancer 
spreads,  and  those  of  the  breast,  which  is  one  of 
the  commonest  sites  of  cancer,  are  of  especial  im- 
portance if  complete  eradication  of  the  disease  is 
to  be  obtained.  The  lymph-vessels  are  arranged 
inthe  following  sets:  (1)  Perilobular,  round  the 
acini  and  lobules;  (2)  periductal,  round  the  lac- 
tiferous ducts;  (3)  interlobar,  situated  in  the 
interlobar  septa  and  joining  (4)  the  retromam- 
mary network  with  (5)  the  superficial  mammary 
in  the  anterior  part  of  the  capsule.  If  the  inter- 
lobar septa  are  invaded  by  cancer  they  contract, 


212  THE    THORAX  [Chap. 

and  through  their  cutaneous  attachments  cause 
depressions  in  the  skin ;  if  the  process  invades  the 
periductal  vessels,  the  nipple  is  retracted.  The 
mammary  lymphatic  system  is  connected  with  the 
subcutaneous  network  of  vessels,  to  which  cancer 
may  spread,  producing  that  variety  of  the  disease 
known  as  cancer  en  cuirasse.  Through  communi- 
cations with  the  lymph  channels  of  the  pectoral 
fascia  and  muscle,  cancer  of  the  breast  may  spread 
to  these  structures.  The  gland  then  becomes 
firmly  fixed  to  the  deeply  seated  structures.  The 
majority  of  the  lymph-vessels  pass  from  the  breast 
to  the  pectoral  glands,  six  to  eight  in  number, 
situated  along  the  anterior  border  of  the  axilla, 
and  to  the  central  axillary  set,  twelve  to  fifteen 
in  number,  situated  beneath  the  axillary  tuft  of 
hair  and  on  the  inner  side  of  the  axillary  vein. 
From  these  two  sets  the  lymph-vessels  pass  to  the 
deep  axillary  glands  lying  along  the  front  and 
inner  side  of  the  axillary  vessels.  The  deep  axil- 
lary glands  become  continuous  with  the  lower  deep 
cervical  glands.  It  is  mainly  along  this  path  that 
cancer  tends  to  spread,  but  vessels  leave  the  inner 
segment  of  the  breast  and  pass  to  the  anterior 
intercostal  glands  situated  in  the  upper  four 
intercostal  spaces  and  lying  on  each  side  of  the 
internal  mammary  vessels,  while  occasionally  a 
few  vessels  pass  to  the  cephalic  gland  situated 
in  the  hiatus  between  the  deltoid  and  pectoralis 
major  muscles.  Handley  found  a  marked  ten- 
dency for  breast  cancer  to  spread  downwards  in 
the  lymphatics,  passing  to  the  epigastric  triangle. 
There  the  vessels  perforate  the  belly  wall  to  join 
lymphatics  both  above  and  below  the  diaphragm  ;  it 
is  probably  owing  to  this  communication  that  the 
liver  is  so  often  the  seat  of  secondary  deposit  in 
cases  of  cancer  of  the  breast.  When  the  normal 
channels  become  clogged  with  cancerous  invasion, 
the  lymph  passes  by  circuitous  paths.  The  sub- 
scapular glands,  surrounding  the  subscapular 
vessels  on  the  posterior  wall  of  the  axilla,  may 
become  infiltrated;  through  the  lymphatics  of  the 


X]  THE    MAMMA  213 

arm,  which  end  in  the  central  axillary  glands, 
the  structures  round  the  shoulder  may  become  the 
seats  of  secondary  deposit,  and  through  the  com- 
munication between  the  lymph  system  of  one 
breast  with  that  of  the  other,  across  the  sternum, 
a  secondary  deposit  may  even  occur  in  the  oppo- 
site breast  (Stiles). 

The  intercosto-humeral  nerve  pierces  the  cen- 
tral set  of  axillary  glands.  It  becomes  compressed 
when  these  glands  are  invaded  by  cancer,  and 
pain  is  referred  to  the  termination  of  the  nerve 
over  the  posterior  aspect  of  the  arm  above  the 
elbow.  Various  parts  of  the  brachial  plexus  may 
also  become  involved  or  the  axillary  vein  or  lym- 
phatics occluded,  the  arm  being  swollen  and 
oedematous   in   consequence. 

The  following  groups  of  arteries  supply  the 
gland  and  are  cut  in  excision  of  the  organ  :  (1) 
the  long  thoracic,  alar  thoracic,  thoracic  oranches 
of  the  acromio-thoracic  axis;  (2)  anterior  perfor- 
ating branches  from  the  internal  mammary  at  the 
second,  third,  and  fourth  intercostal  spaces;  (3) 
lateral  branches  from  the  second,  third,  and 
fourth    intercostal    arteries. 

Supernumerary  nipples  and  breasts  may  occur. 
They  are  commonly  found  in  a  line  between  the 
axilla  and  the  groin.  In  the  embryonic  stage  of 
all  mammals  an  epiblastic  mammary  ridge  is 
found  in  this  position.  In  man  it  disappears 
except  at  one  point,  but  occasionally  some  isolated 
part  may  persist  and  proceed  to  form  a  breast. 
Embryology  fails  to  explain  the  occurrence  of 
breasts  on  the  buttock  or  back,  where  they  are 
occasionally  found. 

The   Thoracic  Viscera 

The  lung.— The  apex  of  the  lung  rises  in  the 
neck  from  1  to  lj  inches  above  the  inner  half  of 
the  clavicle.  Its  highest  point  in  the  majority 
of  adults  lies  lj  inches  above  the  sternal  end  of 
the  clavicle,   in  the  interval  between  the  sternal 


214 


THE    THORAX 


[Chap. 


and  clavicular  heads  of  the  sterno-mastoid  muscle 
(Fig.  47).  The  anterior  edges  of  the  two  lungs 
pass  behind  the  sternoclavicular  articulations, 
and  meet  in  the  middle  line  at  the  junction  of  the 
manubrium  with  the  gladiolus.  The  edge  of  the 
right  lung  then  continues  vertically  downwards 
behind  the  middle  line  of  the  sternum  to  the  sixth 


Pulmonary  Apex 
Claviclc- 
Pleural  Li/ne 
.Stereo-  /"lANUB.Poim 


/Iipple 

Uncovered  Area 
Ster/io-  E/xsifor/i  Powr 

Apex  Point 
Pulmonary  Line 


Pleural  Line 
2" 


Fig.  47. — Diagram  showing  surface  markings  for  the  lungs 
and  pleura. 


chondro-sternal  articulation,  where  it  slopes  off 
along  the  line  of  the  sixth  cartilage.  The  edge  of 
the  left  lung  keeps  close  to  that  of  the  right  as  far 
as  the  fourth  chondro-sternal  articulation,  where 
it  turns  off  to  the  left,  following  a  line  drawn 
from  the  fourth  cartilage  to  near  the  apex  of  the 
heart  (Fig.  47).  Occasionally  it  does  not  diverge, 
but  completely  covers  the  pericardium  up  to  the 
edge  of  the  sternum.     In  the  child,  owing  to  the 


X]  THE    LUNG  215 

thymus,  the  lungs  are  more  separated  in  front. 
The  right  reaches  the  middle  line,  but  the  left  only 
reaches  the  left  edge  of  the  sternum  (Symington). 
The  easiest  and  also  the  most  accurate  method  of 
indicating  the  lower  border  of  the  lung  is  the  fol- 
lowing (tig.  47)  :  A  line  is  drawn  along  the  sixth 
costal  cartnagre  from  its  sternal  end  to  its  heel ; 
from  the  heel  the  line  is  carried  horizontally 
round  the  body ;  it  will  be  found  to  cross  the 
median  line  behind,  at,  or  near  the  eleventh  dorsal 
spine  (the  anticlinal  spine).  The  corresponding 
border  of  the  pleura  is  not  parallel  to  the  lower 
border  of  the  lung ;  it  is  indicated  by  a  line  drawn 
along  the  seventh  costal  cartilage  from  its  sternal 
end  to  its  heel ;  from  there  the  line  is  continued 
to  a  point  2  inches  above  the  lowest  part  of  the 
subcostal  margin  and  then  prolonged  horizontally 
to  the  median  line  behind  where  it  crosses  at  or 
near  the  twelfth  dorsal  spine.  Between  the  pul- 
monary line  above  and  the  pleural  line  below,  the 
diaphragm  is  in  contact  with  the  chest  wall,  separ- 
ated only  by  the  costo-phrenic  reflection  of  the 
pleura.  On  the  left  side  these  lines  commence  at 
a  variable  distance  from  the  sternum — 1  inch 
should  be  allowed  for  the  pleura ;  2j  inches  for  the 
lung  (Fig.  47).  The  pleura  is  in  relation  with 
the  twelfth  rib,  but  occasionally  it  descends  \  an 
inch  or  more  below  the  neck  of  this  rib,  and  may 
be  wounded  in  operations  on  the  kidney  (Fig.  90, 
p.  435).  It  extends  lower  down  in  the  child  than 
in  the  adult.  The  left  lung  descends  to  a  slightly 
lower  level  than  the  right. 

In  penetrating  wounds  involving  the  pleura, 
air  may  enter  the  pleural  cavity,  producing 
pneumothorax,  and  this  air  may  be  subsequently 
pressed  by  the  respiratory  movements  into  the 
subcutaneous  tissues  through  the  wound  in  the 
parietal  pleura,  and  lead  to  surgical  emphysema. 
In  wounds  of  the  lung  without  external  wound, 
as  when  that  organ  is  torn  by  a  fractured  rib, 
the  air  escapes  from  the  lung  into  the  pleura, 
and  may  thence  pass  into  the  subcutaneous  tissues 


216  THE    THORAX  [Chap. 

through  the  pleural  wound,  thus  producing  both 
pneumothorax   and  emphysema. 

It  is  well  to  note  that  emphysema  may  occur 
about  certain  non=penetrating  wounds  of  the  thorax 
when  they  are  of  a  valvular  nature.  In  such 
cases  the  air  is  drawn  into  the  subcutaneous 
tissues  during  one  respiratory  movement,  and  is 
forced  by  another  into  the  cellular  tissue,  the  val- 
vular nature  of  the  wound  preventing  its  escape 
externally.  When  the  pleural  "  cavity  "  is^  opened, 
the  lungs,  owing  to  the  amount  of  elastic  tissue 
they  contain,  undergo  some  degree  of  collapse,  but 
there  is  much  misconception  regarding  the  extent 
to  which  this  takes  place.  Half  the  air  in  the 
lung,  in  some  cases  even  two-thirds,  is  residual 
and  cannot  be  expelled  by  the  passive  collapse  of 
the  lung;  when  the  diaphragm  is  pushed  up  and 
the  ribs  are  pulled  down  by  the  expiratory  efforts 
of  the  muscles  of  the  belly  wall  the  thoracic  space 
may  be  so  reduced  in  size  that  the  lung  still  more 
than  fills  it ;  if  the  glottis  be  closed  a  hernia  of  the 
lung  will  occur  through  the  wound  in  the  chest 
wall.  If,  however,  there  is  a  valvular  orifice  into 
the  pleural  cavity,  so  that  air  can  be  sucked 
in  but  not  expelled  from  it,  every  respiratory 
effort  increases  the  amount  of  air  in  the  pleural 
space ;  then  compression  of  the  lung  and  suffo- 
cation quickly  ensue.  Air  or  fluid  introduced 
within  the  healthy  #  pleural  cavity  is  rapidly 
absorbed.  Macewen  is  of  opinion^  that  collapse  of 
the  lung  is  prevented  bv  the  capillary  attraction 
which  exists  between  the  visceral  and  parietal 
layers  of  the  pleura. 

In  wounds  of  the  lung  the  blood  may  escape 
in  three  directions  :  into  the  tissue  of  the  organ 
('pulmonary  apoplexy),  into  the  bronchi  (causing 
haemoptysis),  and  into  the  pleura  (causing  hsemo- 
thorax).  In  some  instances  the  lung  has  been  rup- 
tured without  wound  and  without  fracture  to  the 
ribs.  These  cases  are  difficult  to  interpret,  and 
probably  the  best  explanation  suggested  is  that 
put  forward  by   M.    Gosselin.     This  surgeon   be- 


X]  NERVE    SUPPLY    OF   THE    PLEURA         211 

lieves  that  at  the  time  of  the  injury  the  lungs  are 
suddenly  filled  and  distended  with  air  by  a  full 
inspiration,  and  that  the  air,  prevented  from 
escaping  by  occlusion  of  the  larynx,  thus  becomes 
pent  up  in  the  pulmonary  tissue,  and  the  lung  not 
being  able  to  recede  from  the  superincumbent  pres- 
sure, its  structure  necessarily  gives  way. 

Owing  to  the  fineness  of  its  capillaries,  and  to 
the  fact  that  all  venous  blood  returned  to  the  heart 
must  pass  through  the  lungs  before  it  can  reach 
other  parts  of  the  body,  it  follows  that  pysemic 
and  other  secondary  deposits  are  more  commonly 
met  with  in  the  lung  than  in  any  other  of  the 
viscera. 

Lung  cavities  resulting  from  tuberculosis,  gan- 
grene, or  bronchiectasis  have  been  successfully 
incised  and  drained,  and  the  same  measure  has 
been  applied  to  hydatid  cysts  of  the  lung.  Deep 
incisions  in  the  lung  are  followed  by  less  haemor- 
rhage than  might  be  expected  from  such  a  vascular 
organ. 

Nerve  supply  of  the  pleura. — In  acute  inflam- 
mation of  the  pleura,  pain  may  be  very  intense, 
and  the  respiratory  movements  on  the  side  affected 
may  be  greatly  diminished  The  pain,  if  in  the 
lower  part  of  the  thorax,  may  be  referred  to  the 
abdomen.  The  explanation  of  these  facts  must 
be  sought  in  the  nerve  supply  of  the  pleura.  The 
costal  pleura  is  supplied  by  the  adjacent  inter- 
costal nerves,  which  also  supply  the  corresponding 
intercostal  muscles.  The  muscles  are  inhibited 
when  the  underlying  parts  of  the  pleura  are  in- 
flamed. The  lower  six  dorsal  nerves  also  supply 
the  abdominal  wall ;  hence  pain  arising  in  the 
costal  pleura  may  be  referred  by  the  patient  to 
the  abdomen,  and  lead  to  a  suspicion  of  abdominal 
disease.  The  diaphragmatic  and  the  mediastinal 
pleura  are  supplied  by  the  phrenic  nerves,  and 
pain  arising  in  these  parts  may  be  referred  to 
the  neck  or  shoulder.  The  cervical  pleura  is  also 
supplied  by  the  phrenic  nerve  (H.  M.  Johnston). 

The  trachea   divides  opposite  the  junction  of 


218  THE    THORAX  [Chap. 

the  manubrium  and  gladiolus  in  front,  and  the 
fourth  dorsal  vertebra  behind. 

Certain  foreign  substances  that  have  been  drawn 
into  the  air-passages  have  shown  a  remarkable 
facility  for  escaping  through  the  parietes.  Thus 
Mr.  Godlee  records  the  case  of  a  child,  from  an 
abscess  in  whose  back  there  escaped  a  head  of 
rye-grass  that  had  found  its  way  into  the  air  pas- 
sages forty-three  days  previously. 

Foreign  bodies  in  the  trachea  and  bronchi  can 
now  be  located  and  extracted  by  aid  of  the 
bronchoscope.  The  mucous  membrane  at  the  bi- 
furcation of  the  trachea  is  highly  sensitive,  and 
the  orifices  of  the  secondary  bronchial  tubes  can 
be  seen  to  contract  and  dilate  by  virtue  of  the 
circular  musculature  in  their  wails. 

The  root  of  the  lung  and  bronchi  can  be  ex- 
posed by  opening  the  dorsal  wall  of  the  thorax 
behind  the  vertebral  border  of  the  scapula.  Rus- 
sell and  Fox  record  the  case  of  a  boy  in  whom  a 
pin,  3  inches  long,  had  slipped  head  downwards 
within  the  trachea,  and  ultimately  lodged  in  the 
lower  division  of  the  left  bronchus.  They  resected 
part  of  the  eighth  rib  from  the  back,  pushed  the 
lung  forwards  to  expose  the  bronchus  at  the  root, 
and  removed  the  pin.  The  root  of  the  lung  re- 
quires to  be  steadied;  through  the  pericardium  it 
is  intimately  bound  to  the  diaphragm  and  follows 
the  movements  of  that  muscle.  In  the  case  men- 
tioned above,  the  boy  was  able  to  leave  the  hospital 
twelve    days   after   the   operation. 

The  heart  and  pericardium.—  The  position 
and  extent  of  the  pericardium  may  be  indicated 
thus  on  the  surface  of  the  thorax  (Fig.  48)  :  Three 
points  are  taken  :  (1)  the  apical,  over  the  apex 
beat,  in  the  fifth  left  intercostal  space,  3j  inches 
from  the  sternum  ;  (2)  the  sterno-manubrial,  mid- 
way between  the  insertions  of  the  second  costal 
cartilages ;  (3)  the  inferior  caval,  1  inch  to  the 
right  of  the  sterno-ensiform  point  and  directly 
superficial  to  the  termination  of  the  inferior  vena 
cava.     When    these    three    points    are    united    by 


THE    PEMCAEDIUM 


210 


curved  lines,  as  in  Fig.  48,  the  area  over  the  peri- 
cardium and  its  contents  is  marked  out.  The 
lower  line  crosses  \  an  inch  or  more  below  the 
sterno-ensiform  point;  if  a  trocar  be  thrust  back- 
wards in  the  angle  between  the  ensiform  process 
and  seventh  left  costal  cartilage,  it  enters  the 
pericardium  just  above  the  diaphragm.     Through 


Right  Int.Juculac  Vein 

Right  Subclavian  Ve 
Right   Innom-Vein 

St e Rio  - /*1an uB.  Poi/t 
Superior  VenaCa* 

Pericardium 
Right  Auricle 

Auriculc  -Ventricular 
qaoov 

Dome. 

StERNOEnSiFOBN   LINE- 

Inferior  Caval  Point 

JTERN0-  ENSiFORH  POlN" 

Inferior  Vena  Cava 


Left  Innom.Vein 

Arch  op  Aorta 
Pulmonary  Art. 

L  Ventricle 

^ipple- 
R.  Ventricle 


Left  Dome: 
Apex  Point 


Fig.  48.— The  relationship  of  the  pericardium  and  heart  to 
the  sternum  and  ribs. 


this  angle  the  pericardium  may  be  drained  ;  by 
resecting  part  of  the  fifth  and  sixth  cartilages 
its  cavity  may  be  explored.  The  right  border  of 
the  pericardium  is  deeply  placed  and  covered  by 
the  right  lung  (Fig.  47) ;  in  health  it  should  not 
project  more  than  1  inch  beyond  the  right  sternal 
border. 

Besides  the  auricles  and  ventricles  the  follow- 
ing parts  are  contained  in  the  pericardium  :  The 


220  THE    THORAX  [Chap. 

terminations  of  the  inferior  and  superior  venae 
cavae;  the  ascending  aorta  and  pulmonary  artery. 
The  position  of  these  parts,  and  of  the  arch  of  the 
aorta  and  its  branches,  is  shown  in  Fig.  48.  It 
will  be  observed  that  more  than  two-thirds  of  the 
anterior  surface  of  the  heart  is  made  up  of  right 
ventricle  and  auricle ;  consequently  it  is  these 
parts  which  are  usually  perforated  in  stabs  of  the 
heart. 

The  heart  may  be  exposed  for  operative  treat- 
ment by  removal  of  the  terminal  inch  or  more  of 
the  fourth  and  fifth  left  costal  cartilages.  The 
heart  may  be  freely  handled  and  sutured ;  the  sur- 
geon's task  is  rendered  difficult  by  its  rapid 
motions  and  the  respiratory  movements  of  the 
pericardium  and  diaphragm.  When  the  heart  is 
wounded,  blood  escapes  into  the  pericardium,  lead- 
ing to  compression  of  the  auricles  and  the  arrest  of 
the  inflow  of  blood.  Hydrops  of  the  pericardium 
may  cause  death  in  a  similar  manner.  Other 
things  being  equal,  a  wound  of  the  ventricle  is 
less  rapidly  fatal  than  is  a  wound  of  the  auricle, 
owing  to  the  thickness  of  the  ventricular  wall, 
and  to  its  capacity  for  contracting  and  prevent- 
ing the  escape  of  blood.  Death  in  cases  of  wound 
of  the  heart  would  appear  in  a  great  number  of 
cases  to  be  due  to  an  impression  upon  the  nervous 
centres  rather  than  to  actual  haemorrhage.  Many 
instances  have  been  recorded  to  show  that  the 
heart  may  be  very  tolerant  of  foreign  bodies  in 
its  substance.  Thus  a  man  lived  for  twenty  days 
with  a  skewer  traversing  the  heart  from  side  to 
side  (Ferrus).  In  another  case  a  lunatic  pushed 
an  iron  rod,  oyer  6  inches  in  length,  into  his 
chest,  until  it  disappeared  from  view,  although  it 
could  be  felt  beneath  the  skin  receiving  pulsation 
from  the  heart.  He  died  a  year  following,  and 
the  metal  was  found  to  have  pierced  not  only  the 
lungs  but  also  the  ventricular  cavities  (Tillaux). 
Wounds  of  the  heart  have  been  sutured,  the  in- 
sertion of  the  stitches  causing  only  momentary 
disturbance   of   its   action.      Travers   has  sutured 


X]  THE    MED1ASTINA  221 

a  wound  of  the  right  ventricle  into  which  he 
was  able  to  place  three  fingers  to  prevent  haemor- 
rhage. Apropos  of  chest  wounds,  Velpeau  cites 
the  case  of  a  man  in  whose  thorax  was  found 
a  part  of  a  foil  that  entirely  transfixed  the  chest 
from  ribs  to  spine,  ahd  that  had  been  introduced 
fifteen  years  before  death.  In  the  museum  of  the 
Royal  College  of  Surgeons  is  the  shaft  of  a  cart 
that  had  been  forced  through  the  ribs  on  the  left 
side,  had  passed  entirely  through  the  chest,  and 
had  come  out  through  the  ribs  on  the  right  side. 
The  patient  had  lived  ten  years. 

Paracentesis  of  the  pericardium. — As  already 
mentioned,  the  pericardium  may  be  tapped  or 
drained  through  the  left  costo  -  ensif orm  angle 
(Fig.  48).  The  extent  to  which  it  is  covered  by 
the  left  pleura  and  lung  is  extremely  variable, 
but  in  the  majority  of  cases  it  may  be  tapped  in 
the  left  fourth  and  fifth  spaces,  up  to  1  inch  from 
the  sternum,  without  injuring  the  pleura.  The 
internal  mammary  artery  descends  in  these  spaces 
J  an  inch  from  the  sternum,  and  divides,  behind 
the  seventh  cartilage,  into  its  superior  epigastric 
and  musculo-phrenic  branches. 

The  media stina.— Abscess  in  the  anterior 
mediastinum  may  have  developed  in  situ,  or  may 
have  spread  down  from  the  neck.  In  like  manner 
posterior  mediastinal  abscesses  may  arise  from 
diseases  of  the  adjacent  spine,  or  lymphatic 
glands,  or  may  be  due  to  the  spreading  down- 
wards of  a  retropharyngeal  or  retro-oesophageal 
collection  of  matter. 

The  employment  of  Rontgen  rays  in  the  diag- 
nosis of  intrathoracic  disease  has  greatly  enlarged 
our  knowledge  of  the  respiratory  movements  and 
relationships  of  the  thoracic  viscera.  In  Fig.  49 
(from  a  careful  drawing  given  by  Dr.  Halls 
Dally)  a  representation  is  given  of  the  more 
important  parts  seen  when  the  chest  is  examined 
in  an  axis  passing  from  the  right  nipple  to 
the  left  scapula  of  the  patient.  The  heart  and 
liver  appear  as  shadows,  moving  downwards  and 


222 


THE   THORAX 


[Chap. 


forwards  in  inspiration,  upwards  and  backwards 
in  expiration.  As  the  diaphragm  descends,  and 
the  heart  moves  away  from  the  spine,  the  pos- 
terior mediastinum,  containing  the  aorta  and 
oesophagus,  appears  as  a  transradiant  triangle. 
With  inspiration,  too,  the  lungs  clear  up  and 
become  more  transparent.  The  anterior  medias- 
tinum also  is  seen  as  a  clear  space.  In  the 
superior   mediastinum   may   be   seen   the  arch   of 


Ant.    Mediastinum 


Diaph.  in  Expirat. 


DlAPH.     IN    INSPIRAT. 


Translucent  Triangle 


Fig.  49.— Orthodiagram  of  the  thorax.       (After  Br.  Halls 
Bally.) 

The  position  of  parts  is  shown  in  extreme  inspiration  ;  the  position 
of  the  diaphragm  and  liver  in  expiration  is  also  shown. 

the  aorta  as  it  passes  backwards  from  the  manu- 
brium to  the  fourth  dorsal  vertebra.  In  the  in- 
dividual from  whom  Dr.  Halls  Dally  constructed 
the  diagram  given  in  Fig.  49,  the  vertical  move- 
ment of  the  diaphragm  amounted  to  3  inches. 
In  normal  respiration  the  vertical  movement 
varies  from  \  to  f  of  an   inch. 

The  azygos  veins,  commencing  as  they  do  below 
in  the  lumbar  veins,  and  having  more  or  less  direct 
communications  with  the  common  iliac,  renal, 
and  other  tributaries  to  the  vena  cava,  are  able 
to  a  great  extent  to  carry  on  the  venous  circula- 


XJ  THOEACIC    DUCT  223 

tion  in  cases  of  obstruction  of  the  terminal  part 
of  the  superior  vena  cava.  In  this  they  are  as- 
sisted by  the  vense  comites  of  the  internal  mam- 
mary artery  and  epigastric  veins;  the  intraverte- 
bral  veins  also  become  greatly  enlarged,  and  serve 
as  anastomotic  channels  between  the  superior  and 
inferior  caval  systems. 

These  veins  are  apt  to  be  pressed  upon  by 
tumours  (such  as  enlarged  gland  masses)  de- 
veloped in  the  posterior  mediastinum,  and  to  pro- 
duce in  consequence  some  oedema  of  the  chest 
walls  by  engorgement  of  those  intercostal  veins 
that  they  receive.  Tumours  growing  in  the  pos- 
terior mediastinum  may  cause  trouble  by  press- 
ing upon  the  trachea  or  gullet,  or  by  disturbing 
the  vagus  nerve  or  the  cord  of  the  sympathetic. 
The  numerous  lymphatic  glands  which  surround 
the  trachea,  bronchi,  and  oesophagus  are  often  the 
seat  of  tuberculosis.  They  become  adherent  to 
these  organs  and  may  ulcerate  into  them. 

Thoracic  duct. — Krabbel  reports  a  case  of 
fracture  of  the  9th  dorsal  vertebra  associated  with 
rupture  of  the  thoracic  duct.  The  patient  died 
in  a  few  days,  and  the  right  pleura  was  found 
to  contain  more  than  a  gallon  of  pure  chyle. 

The  bodies  of  the  upper  lumbar  and  lower 
dorsal  vertebrae  are  frequently  the  site  of  tuber- 
culosis ;  so  are  the  apical  parts  of  the  lungs. 
Dr.  WoodyJones  has  drawn  attention  to  the  close 
relationship  of  these  parts  to  the  thoracic  duct, 
and  to  the  possibility  of  a  tubercular  invasion 
beginning  from  the  alimentary  canal  being  con- 
veyed to  these  sites  of  election  by  the  duct.  The 
receptaculum  chyli  is  formed  on  the  bodies  of 
the  first  and  second  lumbar  vertebrae,  from  which 
the  duct  ascends  in  the  posterior  mediastinum 
in  front  of  the  lower  dorsal  vertebrae.  In  cases 
of  cancer  of  the  stomach,  the  cervical  glands 
round  the  termination  of  the  thoracic  duct  may 
become  enlarged  bv  secondary  growths  at  an  early 
stage  of  the  disease.  The  secondary  dissemination 
takes  place  by  means  of  the  thoracic  duct. 


PART  III.-THE  UPPER  EXTREMITY 

CHAPTER    XI 

THE    REGION    OF    THE    SHOULDER 

A  study  of  the  region  of  the  shoulder  comprises 
the  clavicle,  the  scapula,  the  upper  end  of  the 
humerus,  and  the  soft  parts  that  surround  them, 
together  with  the  shoulder-joint  and  axilla. 

Surface  anatomy.— The  clavicle,  acromion 
process,  and  scapular  spine  are  all  subcutaneous, 
and  can  be  readily  felt.  In  the  upright  position, 
when  the  arm  hangs  by  the  side,  the  clavicle  is, 
as  a  rule,  not  quite  horizontal.  In  well-developed 
subjects  it  inclines  a  little  upwards  at  its  outer 
end.*  In  the  recumbent  posture,  the  weight  of  the 
limb  being  taken  off,  the  outer  end  rises  still 
higher  above  the  sternal  extremity.  The  degree 
of  the  elevation  can  be  best  estimated  by  a  study 
of  frozen  sections.  Thus,  in  making  horizontal 
sections  of  the  body,  layer  by  layer,  from  above 
downwards,  Braune  found  that  by  the  time  the 
sterno-clavicular  articulation  was  reached,  the 
head  of  the  humerus  would  be  cut  across  in  the 
lateral  part  of  the  section   (Fig.   50). 

The  deltoid  tubercle  of  the  clavicle  may,  if 
large,  be  felt  through  the  skin,  and  be  mistaken 

*  Tn  some  women,  in  the  feeble,  and  in  some  narrow-shouldered  men 
the  clavicle  may  be  horizontal,  or  its  outer  end  may  incline  downwards. 

224 


Chap.  XIJ     EEGION    OF    THE    SHOULDER  225 

for  an  exostosis.  The  acromioclavicular  joint  lies 
in  the  plane  of  a  vertical  line  passing  up  the 
middle  of  the  front  of  the  arm.  A  prominence  is 
sometimes  felt  about  this  joint  in  place  of  the 
level  surface  that  it  should  present.  This  is  due 
to  an  enlargement  of  the  end  of  the  clavicle,  or 
to  a  thickening  of  the  fibro-cartilage  sometimes 
found  in  the  joint.  In  many  cases  it  has  ap- 
peared to  me  to  be  due  to  a  trifling  luxation  up- 
wards of  the  clavicle  depending  upon  some  stretch- 
ing of  the  ligaments.  It  is  certain  that  the  dry 
bone  seldom  shows  an  enlargement  such  as  to 
account  for  this  very  common  prominence  at  the 
acromial  articulation.  The  sternal  end  of  the 
clavicle  is  also,  in  muscular  subjects,  often  large 
and  unduly  prominent,  and  sufficiently  conspicu- 
ous to  suggest  a  lesion  of  the  bone  or  joint  when 
none  exists. 

The  roundness  and  prominence  of  the  point  of 
the  shoulder  depend  upon  the  development  of  the 
deltoid  and  the  position  of  the  upper  end  of  the 
humerus.  The  deltoid  hangs  like  a  curtain  from 
the  shoulder  girdle,  and  is  bulged  out,  as  it  were, 
by  the  bone  that  it  covers.  If  the  head  of  the 
humerus,  therefore,  be  diminished  in  bulk,  as  in 
some  impacted  fractures  about  the  anatomical 
neck,  orbe  removed  from  the  glenoid  cavity,  as  in 
dislocations,  the  deltoid  becomes  more  or  less  flat- 
tened, and  the  acromion  proportionately  promi- 
nent. The  part  of  the  humerus  felt  beneath  the 
deltoid  is  not  the  head,  but  the  tuberosities,  the 
greater^  tuberosity  externally,  the  lesser  in  front. 
A  considerable  portion  of  the  head  of  the-  bone 
can  be  felt  by  the  fingers  placed  high  up  in  the 
axilla,  the  arm  being  forcibly  abducted  so  as  to 
bring  the  head  in  contact  with  the  lower  part  of 
the  capsule.  The  head  of  the  humerus  faces  very 
much  in  the  direction  of  the  internal  condyle.  As 
this  relation,  of  course,  holds  good  in  every  posi- 
tion of  the  bone,  it  is  of  value  in  examining 
injuries  about  the  shoulder,  and  in  reducing 
dislocations  by  manipulation,  the  condyle  being 
i 


226  THE    UPPER    EXTREMITY  [Chap. 

used  as  an  index  to  the  position  of  the  upper  end 
of  the  bone. 

In  thin  subjects  the  outline  and  borders  of 
the  scapula  can  be  more  or  less  distinctly  made 
out,  but  in  fat  and  muscular  subjects  all  parts 
of  the  bone,  except  the  spine  and  acromion,  are 
difficult  of  access  in  the  ordinary  positions  of  the 
limb.  To  bring  out  the  superior  angle  and  verte- 
bral border  of  the  bone,  the  hand  of  the  subject 
should  be  carried  as  far  as  possible  over  the  oppo- 
site shoulder.  To  bring  out  the  inferior  angle 
and  axillary  border,  the  forearm  should  be  placed 
behind  the  back.  The  angle  formed  at  the  point 
of  junction  of  the  spine  of  the  scapula  and  the 
acromion  is  the  best  point  from  which  to  take 
measurement  of  the  arm,  the  tape  being  carried 
down  to  the  external  condyle  of  the  humerus.  The 
upper  border  of  the  scapula  lies  on  the  second 
rib,  its  lower  angle  on  the  seventh. 

When  the  arm  hangs  from  the  side  with  the 
palm  of  the  hand  directed  forwards,  the  acromion, 
external  condyle,  and  styloid  process  of  the  radius 
all  lie  in  the  same  line.  The  groove  between  the 
pectoralis  major  and  deltoid  muscles  can  usually 
be  made  out.  In  it  run  the  cephalic  t  vein  and 
a  large  branch  of  the  acromio-thoracic  artery. 
Near  the  groove,  and  a  little  below  the  clavicle, 
the  coracoid  process  may  be  felt.  This  process, 
however,  does  not  actually  present  in  the  interval 
between  the  two  muscles,  but  is  covered  by  the 
innermost  fibres  pi  the  deltoid.  The  position  of 
the  coraco-acromial  ligament  may  be  defined,  and 
a  knife  thrust  through  the  middle  of  it  should 
strike  the  biceps  tendon  and  open  the  shoulder- 
joint. 

When  the  arm  hangs  at  the  side  with  the  palm 
forwards,  the  bicipital  groove^  may  be  defined 
directly  below  the  acromioclavicular  joint. 

Just  below  the  clavicle  is  a  depression,  the  sub- 
clavicular fossa,  which  varies  considerably  in 
depth  in  different  subjects.  It  is  obliterated  in 
subcoracoid  dislocations  of  the  humerus,  in  frac- 


XI]  KEGION    OF    THE    SHOULDER  227 

tures  of  the  clavicle  with  displacement,  by  many 
axillary  growths,  and  by  some  inflammations  of 
the  upper  part  of  the  thoracic  wall.  In  sub- 
clavicular or  infracoracoid  dislocation  the  fossa 
is  replaced  by  an  eminence.  In  this  region,  at  a 
spot  to  the  inner  side  of  the  coracoid  process,  and 
corresponding  nearly  to  the  middle  of  the  clavicle, 
the  pulsations  of  the  axillary  artery  can  be  felt 
against  the  second  rib.  Just  below  the  clavicle 
the  interspace  between  the  sternal  and  clavicular 
portions  of  the  pectoralis  major  can  often  be 
made  out. 

The  anterior  and  posterior  borders  of  the  axilla 
are  very  distinct.  The  anterior  border,  formed 
by  the  lower  edge  of  the  pectoralis  major,  follows 
the  line  of  the  fifth  rib.  The  depression  of  the 
armpit  varies,  other  things  being  equal,  with  the 
position  of  the  upper  limb.  It  is  most  deep  when 
the  arm  is  raised  from  the  side  at  an  angle  of 
about  45°,  and  when  the  muscles  forming  the  bor- 
ders of  the  space  are  in  a  state  of  contraction. 
As  the  arm  is  raised  above  the  horizontal  line  the 
depression  becomes  shallower,  the  head  of  the  bone 
projecting  into  the  space  and  more  or  less  obliter- 
ating it,  while  the  width  of  the  fossa  is  encroached 
upon  by  the  approximation  of  the  anterior  and 
posterior  folds.  The  coraco-brachialis  muscle  itself 
forms  a  distinct  projection  along  the  humeral 
side  of  the  axilla  when  the  arm  is  raised  to  a 
right  angle  with  the  body.  If  the  arm  be  brought 
nearly  close  to  the  side,  the  surgeon's  hand  can 
be  thrust  well  up  into  the  axilla,  and  the  thoracic 
wall  explored  as  high  up  as  the  third  rib. 

The  axillary  glands  cannot  be  felt  when  they 
are  in  a  normal  condition.  The  central  set  lies 
beneath  the  axillary  tuft  of  hair. 

The  direction  of  the  axillary  artery,  when  the 
arm  is  raised  from  the  side,  is  represented  by  a 
line  drawn  from  the  middle  of  the  clavicle  to  the 
humerus  at  the  inner  side  of  the  coraco-brachialis. 
A  line  drawn  from  the  third  rib  near  its  cartilage 
to  the  tip  of  the  coracoid  process  indicates  the 


228 


THE    UPrER    EXTREMITY 


[Chap. 


upper  border  of  the  pectoralis  minor,  and  the  spot 
where  this  line  crosses  the  line  of  the  axillary 
artery  points  out  the  position  of  the  acromio- 
thoracic  artery.     A  line  drawn  from  the  fifth  rib 


Fig.  50.— Horizontal  section  of  the  body  just  below  the 
upper  border  of  the  manubrium.      (Braune.) 

a,  Manubrium  ;  b,  head  of  humerus  ;  c,  clavicle  ;  d,  first  rib  ;  e,  second 
rib  ;  /,  third  dorsal  vertebra  ;  g,  spine  of  second  dorsal ;  h,  pec- 
toralis  major ;   i,  deltoid  ;  j,  infraspinatus  ;   k,  subscapularis ; 

1,  coraco-brachialis  and  biceps  ;  m,  pectoralis  minor  ;  n,  serratus 
magnus  ;  o,  intercostals  ;  p,  semispinalis  and  multifidus  spinsB  ; 
<7,  biventer  cervicis  and  complexus  ;  r,  longissimus  dorsi ;  s,  sple- 
nius  colli ;  t,  rhomboideus  ;  w,  trapezius  ;  v,  sterno-thyroid  ; 
w,  sterno-hyoid ;  T,  thymus ;  L,  lung  ;  1,  left  innominate  vein ; 

2,  left  carotid  artery ;  3,  left  subclavian  artery ;  4,  vertebral 
artery  ;  5,  left  subclavian  vein  ;  6,  cephalic  vein  ;  7,  phrenic  nerve  ; 
8,  vagus  ;  9,  transverse  scapular  artery. 

near  its  cartilage  to  the  tip  of  the  coracoid  process 
indicates  the  lower  border  of  the  pectoralis  minor, 
and  the  position  of  the  long  thoracic  artery  which 
runs  along  that  border.  The  line  of  the  sub- 
scapular artery  corresponds  to  the  lower^  border 
of  the  subscapularis  muscle  along  which  it  runs, 


XI]  THE    CLAVICLE  229 

but  the  position  of  this  border  can  only  be  ap- 
proximately indicated  on  the  living  or  undissected 
subject. 

The  circumflex  nerve  and  posterior  circumflex 
artery  cross  the  humerus  in  a  horizontal  line  that 
is  about  a  finger's  breadth  above  the  centre  of  the 
vertical  axis  of  the  deltoid  muscle.  This  point 
is  of  importance  in  cases  of  supposed  contusion 
of  the  nerve.  These  various  indications  of  the 
positions  of  the  main  branches  of  the  axillary 
artery  are  made  while  the  arm  hangs  in  its 
natural  position  at  the  side.  The  dorsalis  sca- 
pulae artery  crosses  the  axillary  border  at  a  point 
corresponding  to  the  centre  of  the  vertical  axis 
of  the   deltoid. 

The  clavicle. — The  skin  over  the  clavicle  is 
loosely  attached,  and  is  easily  displaced  about  the 
bone.  This  circumstance  may  serve  to  explain 
why  the  skin  so  often  escapes  actual  wound  in 
contusions  of  the  clavicular  region,  and  in  part 
explains  the  infrequency  of  penetration  of  the 
integument  in  fractures  of  the  clavicle.  The 
three  supraclavicular  nerves  that  cross  the  clavicle 
are  branches  of  the  third  and  fourth  cervical 
nerves,  and  it  is  well  to  note  that  pain  over  the 
collar  bone  is  sometimes  a  marked  feature  in 
disease  of  the  upper  cervical  spine.  This  symp- 
tom is  then  due  to  irritation  of  these  nerves  at  their 
points  of  exit  from  the  spinal  canal.  A  communica- 
tion between  the  external  jugular  and  cephalic 
veins  is  occasionally^  seen  to  cross  the  clavicle. 

Beneath  the  clavicle  the  great  vessels  and  the 
great  nerve-cords  lie  upon  the  first  rib.  The  vein 
is  the  most  internal,  and  occupies  the  acute  angle 
between  the  collar-bone  and  the  first  rib.  It  will 
be  seen  that  growths  from  the  bone  may  readily 
press  upon  these  important  structures,  and  that 
the  vein,  from  its  position,  as  well  as  from  the 
slighter  resistance  that  it  offers,  is  likely  to  be 
the  first  to  be  compressed.  These  structures  have 
also  been  wounded  by  fragments  of  bone  in 
fracture    of    the   clavicle.      Fortunately,    between 


230  THE    UPPER    EXTREMITY  [Chap. 

the  clavicle  and  these  large  nerves  and  vessels 
the  subclavius  muscle  is  interposed.  This  muscle 
is  closely  attached  to  the  under  surface  of 
the  bone,  is  enveloped  in  a  dense  fascia,  and 
forms  one  of  the  chief  protections  to  the  ves- 
sels in  case  of  fracture.  This  interposing  pad 
of  muscle  is  also  of  great  service  in  resection 
operations.  Braune  states  that  by  pressing  the 
clavicle  against  the  first  rib  in  the  dead  body 
a  stream  of  injection  in  the  thoracic  duct  can,  in 
some  cases,  be  entirely  arrested.  Behind  the 
clavicle  the  following  structures  may  be  noted, 
viz.  the  innominate,  subclavian,  and  external 
jugular  veins,  the  subclavian,  suprascapular,  and 
internal  mammary  arteries,  the  cords  of  the 
brachial  plexus,  the  phrenic  nerve  and  nerve  of 
Bell,  the  thoracic  duct,  the  omo-hyoid,  scalene, 
sterno-hyoid  and  sterno-thyroid  muscles,  and  the 
apex  of  the  lung.  The  sternal  end  of  the  bone  is 
not  far  removed  from  the  innominate  or  left 
carotid  artery,  the  vagus  and  recurrent  nerves, 
the  trachea,  and  the  oesophagus. 

These  relations  of  the  clavicle  are  given  to  show 
the  dangers  in  the  way  of  partial  _  or  complete 
resections  of  the  bone.  The  difficulties  and  risks 
of  the  operation  increase  as  one  progresses  from 
the  acromial  to  the  sternal  end.  Resection  of  the 
acromial  third  of  the  bone  is  comparatively  easy, 
but  resection  of  the  sternal  portion  is  difficult 
and  dangerous.  The  entire  clavicle  has  been  re- 
moved with  success,  and  the  operation  has  been 
followed  by  less  impairment  of  the  arm  movements 
than  would  be  imagined. 

The  clavicle  forms  the  sole  direct  bony  con- 
nexion between  the  upper  limb  and  the  trunk, 
and  in  severe  accidents,  this  connexion  being 
broken  through,  it  is  possible  for  the  extremity 
to  be  torn  off  entire.  Thus  Billroth  reports  the 
case  of  a  boy  aged  14,  whose  right  arm,  with 
the  scapula  and  clavicle,  was  so  torn  from  the 
trunk  by  a  machine  accident  that  it  was  only 
attached  by  a  strip  of  skin  2  inches  wide.     Other 


XI]  FRACTURES    OF    THE    CLAVICLE  231 

similar  cases  of  avulsion   of  the  limb  have  been 
reported. 

Fractures  of  clavicle, — The  clavicle  is  more  fre- 
quently broken  than  is  any  other  single  bone  in 
the  body.  This  frequency  is  explained  by  the  fact 
that  the  bone  is  very  superficial,  is  in  a  part 
exposed  to  injury,  is  slender  and  contains  much 
compact  tissue,  is  ossified  at  a  very  early  period 
of  life,  and  above  all  receives  a  large  part  of  all 
shocks  communicated  to  the  upper  extremity.  The 
common  fracture,  that  due  to^  indirect  violence,  is 
oblique,  and  very  constant  in  its  position,  viz. 
at  the  outer  end  of  the  middle  third  of  the  bone. 
So  closely  is  the  outer  third  of  the  clavicle  bound 
by  ligaments  to  the  coracoid  and  acromion  pro- 
cesses that  it  may  be  regarded  as  part  of  the 
scapula.  Hence  the  impact  resulting  from  a  fall 
on  the  shoulder  is  transferred  to  the  clavicle  at 
the  junction  of  its  outer  and  middle  thirds.  The 
bone  breaks  at  the  point  where  the  force  is  trans- 
ferred to  the  clavicle  from  the  scapula.  -  The  posi- 
tion of  the  coraco-clavicular  ligaments  is  no  doubt 
of  the  greatest  import  in  localizing  the^  fracture 
in  this  position,  since  a  clavicle  experimentally 
subjected  to  longitudinal  compression  does  not 
break  at  this  spot  (Bennett). 

The  displacement  that  occurs  is  as  follows.  The 
inner  fragment  remains  unchanged  in  position,  or 
its  outer  end  is  drawn  a  little  upwards  by  the 
sterno-mastoid.  It  will  be  seen  that  any  action  of 
this  muscle  would  be  resisted  by  the  pectoralis 
major  and  the  rhomboid  ligament.  The  outer  frag- 
ment undergoes  a  threefold  displacement.  (1)  It  is 
carried  directly  downwards.  This  is  effected  mainly 
by  the  weight  of  the  limb  aided  by  the  pectoralis 
minor,  the  lower  fibres  of#  the  pectoralis  major, 
and  the  latissimus  dorsi.  (2)  It  is  carried 
directly  inwards  by  the  muscles  that  pass  from 
the  trunk  to  the  jshpulder,  viz.  the  levator  anguli 
scapulae,  the  latissimus  dorsi,  and  especially  by 
the  pectorals.  (3)  The  fragment  is  rotated  in 
such  a  way  that  the  outer  end  projects  forwards, 


232  THE    UPPER    EXTREMITY  [Chap. 

the  inner  end  backwards.  This  rotation  is 
brought  about  mainly  by  the  two  pectorals,  as- 
sisted prominently  by  the  serratus  magnus.  The 
normal  action  of  this  latter  muscle  is  to  carry  the 
scapula  forwards,  and  the  clavicle,  acting  as  a 
kind  of  outrigger  to  keep  the  upper  limb  at  a 
proper  distance  from  the  trunk,  moves  forwards 
at  the  same  time  and  keeps  the  scapula  direct. 
When  this  outrigger  is  broken  the  serratus  can  no 
longer  carry  the  scapula  directly  forwards.  The 
bone  tends  to  turn  towards  the  trunk,  and  the 
point  of  the  shoulder  is  therefore  seen  to  move 
inwards  as  well  as  forwards.  The  fragments  in 
this  fracture  must  consequently  overlap,  and  as 
the  displacement  is  difficult  to  remedy,  it  follows 
that  in  no  bone  save  the  femur  is  shortening  so 
uniformly  left  as  after  an  oblique  fracture  of  the 
clavicle.  The  degree  of  shortening  very  seldom 
exceeds  one  inch.  The  deformity  associated  with 
this  fracture  is  well  corrected  when  the  patient 
assumes  the  recumbent  position.  In  this  posture, 
the  weight  of  the  limb  being  taken  off,  the  down- 
ward displacement  is  at  once  remedied.  The 
"point  of  the  shoulder  falling  back  also  tends  to 
relieve  in  part  the  inward  displacement,  and  the 
rotation  of  the  outer  fragment  forwards.  It  is 
through  the  scapula,  however,  that  these  two  latter 
displacements  are  in  the  main  removed.  In  the 
recumbent  posture  the  scapula  is  pressed  closely 
against  the  thorax,  with  the  result  that  its  outer 
extremity  (and  with  it,  of  course,  the  outer  frag- 
ment of  the  clavicle)  is  dragged  outwards  and 
backwards.  Some  surgeons,  recognizing  this  im- 
portant action  of  the  scapula  in  remedying  the 
displacement  in  these  cases,  strap  the  scapula 
firmly  against  the  trunk,  while  at  the  same  time 
they  elevate  the  arm. 

Fractures  due  to  direct  violence  are  usually 
transverse,  and  may  be  at  any  part  of  the  bone. 
When  about  the  middle  third  they  present  the  dis- 
placement just  described.  WThen  the^  fracture  is 
between   the   conoid   and   trapezoid   ligaments   no 


XI]  FRACTURES    OF    THE    CLAVICLE  233 

displacement  is  possible.  When  beyond  these  liga- 
ments, the  outer  end  of  the  outer  fragment  is  car- 
ried forwards  by  the  pectorals  and  serratus,  and 
its  inner  end  is  a  little  drawn  up  by  the  trapezius. 
In  this  fracture  there  is  no  general  displacement 
downwards  of  the  outer  fragment,  since  it  can- 
not move  in  that  direction  unless  the  scapula  go 
with  it,  and  the  scapula  remains  fixed  by  the 
coraco-clavicular  ligaments  to  the  inner  fragment 
of  the  clavicle. 

The  clavicle  may  be  broken  by  muscular  vio- 
lence alone.  Polaillon,  from  a  careful  analysis  of 
the  reported  cases,  concludes  that  the  muscles  that 
break  the  bone  are  the  deltoid  and  clavicular 
part  of  the  great  pectoral.  In  no  case  does  the 
fracture  appear  to  have  been  produced  by  the 
sterno-mastoid  muscle.  The  commonest  movements 
producing  fracture  appear  to  be  violent  move- 
ments of  the  limb  forwards  and  inwards,  or  up- 
wards. These  fractures  are  usually  about  the 
middle  of  the  bone,  and  show  no  displacement 
other  than  that  of  both  fragments  forwards,  i.e. 
in  the  direction  of  the  fibres  of  the  two  muscles 
first  named. 

The  clavicle  is  more  frequently  the  seat  of 
green-stick  fracture  than  is  any  other  bone  in  the 
body.  Indeed,  one-half  of  the  cases  of  broken 
collar-bone  occur  before  the  age  of  five  years. 
This  is  explained  by  the  fact  that  the  bone  is 
ossified  at  a  very  early  period,  and  is  in  a  break- 
able condition  at  a  time  when  most  of  the  other 
long  bones  still  present  much  unossified  cartilage 
in  their  parts.  Moreover,  the  periosteum  of  the 
clavicle  is  unduly  thick,  and  not  very  closely 
attached  to  the  bone,  circumstances  that  greatly 
favour  subperiosteal  fracture. 

A  reference  to  the  relations  of  the  bone  will 
show  that  important  structures  may  be  wounded 
in  severe  fractures  associated  with  much  displace- 
ment and  with  sharp  fragments.  Several  cases 
are  reported  of  paralysis  of  the  upper  limb  (as  a 
rule  incomplete)  following  upon  fracture  of  this 
I* 


234  THE    UPPER    EXTREMITY  [Chap 

bone.  In  some  #  cases  this  symptom  was  due  to 
actual  compression  or  tearing  of  some  of  the  great 
nerve  cords  by  the  displaced  fragments.  In  other 
cases  the  nerve  injury,  while  due  to  the  original 
accident,  was  yet  independent  of  the  broken  clavi^ 
cle.  Paralysis  of  the  biceps,  brachialis  anticus, 
and  supinator  longus,  muscles  supplied  through 
the  upper  cord,  may  result  from  heavy  weights 
being  carried  on  the  shoulder.  Cases  are  reported 
of  wound  of  the  subclavian  artery,  of  the  sub- 
clavian vein,  of  the  internal  jugular  vein,  and  of 
the  acromio-thoracic  artery.  In  several  instances 
the  fracture  has  been  associated  with  wound  of  the 
lung,  with  or  without  a  fracture  of  the  upper  ribs. 

The  clavicle  begins  to  ossify  before  any  bone  in 
the  body.  At  birth  the  entire  shaft  is  bony,  the 
two  ends  being  still  cartilaginous.  There  is  one 
epiphysis  for  its  sternal  end  which  appears  be- 
tween the  eighteenth  and  twentieth  year,  and  joins 
the  shaft  about  twenty-nve.^  It  is  a  mere  shell,  is 
closely  surrounded  by  the  ligaments  of  the  sternal 
joint,  and  cannot,  therefore,  be  well  separated  by 
accident.*  In  cases  where  the  clavicle  is  described 
as  congenitally  absent,  the  membrane-formed 
part  of  the  bone  is  represented  by^  a  ligamentous 
cord;  the  cartilage-formed  extremities  are  repre- 
sented by  bony '  nodules.  Defective  ossification 
of  the  clavicle  is  commonly  associated  with  an 
imperfect  ossification  of  the^  membrane-formed 
bones  of  the  skull,  the  condition  being  known 
as  cranio-cleido-dysostosis,  a  disease  of  which 
Mr.  D.  Fitzwilliams  has  recently  collected  sixty 
examples.  The  defect  in  the  clavicle  may  be  so 
limited  as  to  resemble  a  fracture. 

Sterno-clavicular  joint.  —  Although  this  is 
the  only  articulation  that  directly  connects  the 
upper  limb  with  the  trunk,  yet  it  is  possessed  of 

*  Mr.  Heath  {Lancet,  Nov.  18,  1S82)  reports  a  case  which  is  probably 
unique.  It  concerns  a  lad,  aged  14,  who,  when  in  the  act  of  bowling  at 
cricket,  tore  the  clavicle  away  from  its  epiphyseal  cartilage,  which 
remained  in  situ.  The  muscle  producing  the  accident  was  apparently  the 
pectoralis  major. 


XIJ  STEKNO-CLAVICULAK    JOINT  235 

such  considerable  strength  that  luxation  at  the 
joint  is  comparatively  rare.  The  amount  of  move- 
ment in  the  joint  depends  to  a  great  extent  upon 
the  lack  of  adaptability  between  the  facets  on  the 
sternum  and  the  sternal  end  of  the  clavicle.  The 
disproportion  between  these  parts  is  maintained 
by  the  interarticular  cartilage,  which  reproduces 
only  the  outline  of  the  clavicular  surface.  The 
cavity  of  the  joint  is  V-shaped,  since  the  clavicle 
only  touches  the  socket  atits  inferior  angle  when 
the  arm  hangs  by  the  side.  When  the  arm  is 
elevated,  however,  the  two  bones  are  brought  in 
more  immediate  contact,  and  the  joint  cavity  be- 
comes a  mere  slit.  Thus,  in  disease  of  this  articu- 
lation it  will  be  found  that  of  all  movements  of 
the  joint  the  movement  of  the  limb  upwards  is  the 
most  constant  in  producing  pain.  The  joint  is 
supplied  by  the  suprasternal  nerve. 

The  movements  permitted  at  this  joint  are 
limited,  owing  to  '  the  anterior  and  posterior 
sterno-clavicular  ligaments  being  moderately 
tense  in  all  positions  of  the  clavicle.  Movement 
forwards  of  the  clavicle  on  the  sternum  is  checked 
by  the  posterior  ligament,  and  resisted  by  the  an- 
terior ligament.  This  latter  ligament  ismore  lax 
and  less  substantial  than  is  the  posterior  band. 
Its  weakness  serves  in  part  to  explain  the  fre- 
quency of  the  dislocation  forwards. 

Movement  of  the  clavicle  backwards  on  the 
sternum  is  checked  by  the  anterior  ligament,  while 
the  passage  of  the  head  of  the  bone  is  resisted 
by  the  powerful  posterior  band.  The  movement 
is  also  opposed  by  the  rhomboid  ligament.  To 
produce,  therefore,  a  dislocation  backwards  con- 
siderable force  must  be  used. 

Disease  of  the  sternoclavicular  joint.  —  This 
articulation ^  is  really  divided  into  two  joints  by 
the  interarticular  cartilage,  each  being  provided 
with   a   distinct   synovial   membrane. 

These  joints  are  liable  to  the  ordinary  maladies 
of  joints,  and  it  would  appear  that  the  disease 
may  commence  in,  and  be  for  some  time  limited 


•236  THE    UPPEE    EXTREMITY  [Chap. 

to,  only  one  of  the  synovial  sacs.  In  time  the 
whole  articulation  usually  becomes  involved,  but 
even  in  advanced  cases  the  mischief  is  sometimes 
restricted  to  the  synovial  cavity  on  one  side  of  the 
cartilage.  According  to  some  authors,  this  joint 
is  more  frequently  involved  in  pyaemia  than  is  any 
other.  When  effusion  has  taken  place  into  the 
sterno-clavicular  joint,  and  especially  after  sup- 
puration has  ensued,  the  swelling  usually  makes 
itself  evident  in  front,  owing  to  the  fact  that  the 
anterior  sterno-clavicular  ligament  is  the  thinnest 
and  least  resisting  of  the  ligamentous  structures 
about  the  articulation.  For  the  same^  reason  the 
pus  usually  escapes  from  the  anterior  surface 
when   it  discharges   itself  spontaneously. 

Dislocations  of  the  sterno-clavicular  joint.  — The 
clavicle  may  be  dislocated  from  the  sternum  in 
one  of  three  directions,  which,  given  in  order 
of  frequency,  are  :  (1)  forwards,  (2)  backwards, 
(3)  upwards.  The  relative  frequency  of  these  dis- 
locations can  be  understood  from  what  has  been 
already  said  as  to  the  action  of  the  ligaments  in 
restricting  movements.  The  displacement  for- 
wards involves  entire  rupture  of  the  capsule,  and 
more  or  less  damage  to  the  rhomboid  ligament. 
The  head  of  the  bone,  carrying  with  it  the  sterno- 
mastoid,  rests  on  the  front  of  the  manubrium. 
The  dislocation  backwards  may  be  due  to  direct 
or  indirect  violence,  and  has  occurred  spontane- 
ously in  connexion  with  the  chest  deformity  in 
Pott's  disease.  The  capsule  is  entirely  torn,  as  is 
also  the  rhomboid  ligament.  ^  The  head  is  found 
in  the  connective  tissue  behind  the  sterno-hyoid 
and  sterno-thyroid  muscles.  In  this  position  it 
may  cause  severe  dyspnoea,  or  dysphagia,  by 
pressure  upon  the  trachea  or  gullet.  <  In  the 
luxation  upwards,  due  usually  to  indirect  vio- 
lence, the  head  rests  on  the  upper  border  of  the 
sternum  between  the  sterno-mastoid  and  sterno- 
hyoid muscles.  It  involves  more  or  less  complete 
tearing  of  all  the  ligaments  of  the  joint,  together 
with  avulsion  of  the  interarticular  fibro-cartilage. 


XI]  ACH0MI0-CLAV1CULAE    JOINT  237 

The  non-adaptability  of  the  joint  surfaces  in 
this  part  serves  to  explain  the  ease  with  which 
these  luxations  are  usually  reduced,  and  the  diffi- 
culty of  retaining  the  clavicle  in  position  after  it 
is  replaced. 

A  <•  io  in  i  o-c  I  :i  \  i  <•  n  I  a  r  joint. — This  articulation 
is  shallow,  and  the  outlines  of  the  two  bones  that 
enter  into  its  formation  are  such  that  no  obstacle 
is  offered  to  the  displacement  of  the  clavicle  from 
the  acromion.  The  joint,  indeed,  depends  for  its 
strength  almost  entirely  upon  its  ligaments.  The 
plane  of  the  joint  would  be  represented  by  a  line 
drawn  from  above  downwards  and  inwards  be- 
tween the  two  bones.  This  inclination  of  the  joint 
surfaces  serves  to  explain  the  fact  that  the  usual 
luxation  of  this  part  takes  the  form  of  a  displace- 
ment of  the  clavicle  upwards  on  to  the  acromion. 
The  capsule  that  surrounds  the  joint  is  lax  and 
feeble,  and  it  is  partly  from  its  comparative  thin- 
ness that  effusion  into  this  joint,  when  it  is  the 
seat  of  disease,  makes  itself  so  soon  visible.  The 
joint,  however,  depends  mainly  for  its  strength 
upon  the  powerful  conoid  and  trapezoid  liga- 
ments. The  effects  of  shock  at  this  joint  are  les- 
sened by  the  presence  of  a  partial  fibro-cartilage 
which  projects  between  the  bones  from  the  upper 
part  of  the  capsule. 

As  the  movements  permitted  in  this  joint  may 
be  impaired  by  accident  or  disease,  it  is  well  to 
note  the  part  the  articulation  takes  in  the  move- 
ments of  the  extremity.  The  scapula  (and  with  it, 
of  course,  the  arm),  as  it  glides  forwards  and 
backwards  upon  the  thorax,  moves  in  the  arc  of  a 
circle  whose  centre  is  at  the  sterno-clavicular 
joint,  and  whose  radius  is  the  clavicle.  As  the 
bone  moves  forwards  it  is  important,  for  reasons 
to  be  immediately  given,  that  the  glenoid  cavity 
should  also  be  directed  obliquely  forwards.  This 
latter  desirable  condition  is  brought  about  by 
means  of  the  acromio-clavicular  joint.  Without 
this  joint  the  whole  scapula  as  it  passed  forwards 
with  the  outer  end  of  the  clavicle  would  precisely 


238  THE    UPPEK    EXTKEMITY/  [Chap. 

follow  the  line  of  the  circle  above  mentioned,  and 
the  glenoid  cavity  would  look  in  an  increasingly 
inward  direction.  It  is  essential  that  the  surface 
of  the  glenoid  cavity  should  be  maintained  as  far 
as  possible  at  right  angles  to  the  long  axis  of  the 
humerus.  When  these  relations  are  satisfied,  the 
humerus  has  the  support  behind  of  a  stout  sur- 
face of  bone,  and  it  is  partly  to  obtain  the  value 
of  this  support  that  the  boxer  strikes  out  from 
the  side,  i.e.  with  his  humerus  well  backed  up  by 
the  scapula.  If  there  were  no  acromio-clavicular 
joint  the  glenoid  fossa  would  offer  little  support 
to  the  humerus  when  the  limb  was  stretched  for- 
wards, and  a  blow  given  with  the  limb  in  that 
position,  or  a  fall  upon  the  hand  under  like  con- 
ditions, would  tend  to  throw  the  humerus  against 
the  capsule  of  the  shoulder-joint,  and  so  produce 
dislocation.  Normally,  therefore,  as  the  scapula 
and  arm  advance,  the  angle  between  the  acromion 
and  the  adjacent  portion  of  the  clavicle  becomes 
more  and  more  acute,  and  the  glenoid  fossa  is 
maintained  with  a  sufficiently  forward  direction 
to  give  substantial  supportto  the  humerus.*  It 
will  thus  be  seen  that  rigidity  of  this  little  joint 
may  be  a  cause  of  insecurity  in  the  articulation 
of  the  shoulder,  and  of  weakness  in  certain  move- 
ments of  the  limb.  There  is  also  movement  in 
this  joint  as  the  arm  is  lifted  towards  the  head, 
the  angle  between  the  clavicle  and  axillary  border 
becoming  more  acute  as  the  shoulder  is  elevated. 

Dislocations  of  the  acromioclavicular  joint.— 
The  clavicle  may  be  displaced  upwards  on  to 
the  acromion  or  downwards  beneath  it.  Polail- 
lon  has  collected  thirty-eight  cases  of  the  former 
luxation,  and  six  only  of  the  latter.  This  dis- 
proportion is,  in  the  main,  explained  by  the 
direction  of  the  articulating  surfaces  of  the  joint. 
Both  luxations  are  usually  due  to  direct  violence. 
The   dislocation  upwards  is  very  commonly  only 

*  For  an  excellent  account   of  the  mechanism  of  these  joints,  see 
Morris's  "  Anatomy  of  the  Joints,"  p.  202  et  seq. 


XI]  THE    SCAPULA  239 

partial,  and  is  associated  only  with  stretching 
and  some  trifling  rupture  of  ligaments.  In  the 
complete  form,  where  the  end  of  the  clavicle  rests 
entirely  upon  the  acromion,  there  is  rupture,  not 
only  of  the  capsule,  but  also  to  a  greater  or  less 
extent  of  the  coraco-clavicular  ligaments.  In  the 
complete  dislocation  downwards,  also,  there  is  a 
rupture  of  the  capsule,  with  extensive  tearing 
of  the  conoid  and  trapezoid  ligaments.  These 
luxations  are  usually  easily  reduced,  but  it 
will  be  understood,  from  the  direction  of  the 
articular  surfaces,  that  in  the  displacement  up- 
wards it  is  very  difficult  to  retain  the  clavicle  in 
situ  when  once  reduced. 

Scapula.  —  At  the  posterior  aspect  of  the  bone 
the  muscles  immediately  above  and  below  the  spine 
are  somewhat  precisely  bound  down  by  the  deep 
fascia.  Thus,  the  supraspinatus  muscle  is  en- 
closed  in  a  fascia  that,  being  attached  to  the  bone 
all  round  the  origin  of  the  muscle,  forms  a  cavity 
open  only  towards  the  insertion  of  the  muscle. 

The  infraspinatus  and  teres  minor  muscles  are 
also  enclosed  in  a  distinct,  but  much  denser,  fascia 
that  is  attached  to  the  bone  beyond  these  muscles, 
and  blends  in  front  with  the  deltoid  sheath  so  as 
to  form  a  second  enclosed  space.  The  arrange- 
ment of  these  fasciae  serves  to  explain  the  trifling 
amount  of  ecchymosis  that  usually  follows  upon 
fractures  of  the  scapular  blade.  The  extravasa- 
tion of  blood  about  the  fracture  is  bound  down 
by  the  fasciae  over  these  muscles,  and  is  unable, 
therefore,  to  reach  the  surface. 

Movements  of  the  scapula. — In  lifting  the  arm 
from  the  side  to  a  vertical  position  over  the 
head,  the  scapula  undergoes  a  free  rotatory 
movement,  t  its  vertebral  border  passing  from 
an  approximately  vertical  to  an  approximately 
horizontal  position.  At  the  commencement  of 
the  movement,  until  the  arm  has  ascended  35 
degrees  from  the  side,  the  angle  of  the  scapula 
is  practically  stationary ;  during  this  stage  the 
scapula  is  fixed  and  maintained   in  position   by 


240  THE    UPPER    EXTREMITY  [Chap. 

the  trapezius,  rhomboids,  and  serratus  magnus. 
If  the  trapezius  is  paralysed,  as  may  result 
from  accidental  section  of  the  spinal  accessory 
nerve  in  removing  glands  from  the  neck,  the 
angle  and  vertebral  border  project  backwards, 
under  the  weight  of  the  raised  arm.  When  the 
arm  passes  beyond  35  degrees,  the  serratus  magnus 
comes  into  action,  and  the  angle  of  the  scapula 
moves  rapidly  forwards.  If  the  nerve  to  this 
muscle  be  paralysed  (the  nerve  of  Bell  from 
5,  6,  7  c.)  or  if  its  antagonists — the  rhomboids — 
which  are  also  then  in  action,  be  paralysed  (nerve 
from  5  a),  then  the  angle  and  posterior  border  of 
the  scapula  become  prominent  or  "  winged  " — 
evidence  of  the  paralysis  of  these  muscles.  Thus 
"winging"  of  the  scapula  at  the  commencement 
of  the  movement  indicates  paralysis  of  the  trape- 
zius ;  if  it  occurs  after  the  movement  is  well  begun, 
then  the  serratus  magnus  is  affected. 

Fractures  of  the  scapula,  and  especially  of  the 
body  of  the  bone,  are  not  common,  owing  to  the 
mobility  of  the  part  and  the  thick  muscles  that 
cover  in  and  protect  its  thinner  portions.  It  rests 
also  upon  a  soft  muscular  pad,  and  derives,  no 
doubt,  additional  security  from  the  elasticity  of 
the  ribs. 

The  most  common  lesion  is  a  fracture  of  the 
acromion  process.  This  is  often  but  a  separation 
of  the  epiphysis.  There  are  two,  sometimes  three, 
epiphyseal  centres  for  the  acromion.  Ossification 
appears  in  them  about  puberty,  and  the  entire 
epiphysis  joins  with  the  rest  of  the  bone  from  the 
twenty-second  to  the  twenty-fifth  year.  Several 
cases  of  supposed  fracture  of  the  acromion  united 
by  fibrous  tissue  are  probably  but  instances  of  an 
imperfectly-united  epiphysis,  and  may  have  been 
independent  of  injury.  In  five  bodies  out  of  forty 
Symington  found  the  acromial  epiphysis  united 
to  the  spine  by  a  fibrous  union,  and  from  the 
statistics  of  other  observers  it  appears  that  this 
is  the  case  in  quite  10  per  cent,  of  adults.  In 
fractures    of    the    process    much    displacement    is 


XI]  FKACTURES    OF   THE    SCAPULA  241 

quite  uncommon,  owing  to  the  dense  fibrous  cover- 
ing the  bone  derives  from  the  two  muscles  attached 
to  it.  This  dense  periosteum  also  explains  the 
circumstance  that  many  fractures  are  incomplete 
and  crepitus  is  often  absent.  When  the  fracture 
is  in  front  of  the  clavicular  joint,  displacement  of 
the  arm  is  impossible.  When  it  involves  the  joint, 
a  dislocation  of  the  collar  bone  is  common.  When 
behind  the  joint,  the  arm,  having  lost  its  sup- 
port from  the  thorax,  is  displaced  in  somewhat  the 
same  way  as  obtains  in  the  common  fracture  of 
the  clavicle.  The  coracoid  process  may  present  a 
genuine  fracture,  or  may  be  separated  as  an 
epiphysis.  As  an  epiphysis,  it  joins  the  main 
bone  about  the  age  of  seventeen.  The  supra- 
glenoid  tubercle,  from  which  the  long  head  of  the 
biceps  takes  its  origin,  is  part  of  the  coracoid 
epiphysis.  In  spite  of  the  powerful  muscles  at- 
tached to  it,  the  displacement  is  usually  slight, 
inasmuch  as  the  coraco-clavicular  ligaments  are 
seldom  torn.  These  ligaments,  it  may  be  noted, 
are  attached  to  the  base  of  the  process.  In  some 
few  cases  the  process  has  been  torn  off  by  mus- 
cular violence. 

Among  the  more  usual  fractures  of  the  body  of 
the  scapula  is  a  transverse  or  oblique  fracture 
of  its  blade  below  the  spine.  Owing  to  the  infra- 
spinatus, subscapulars,  and  other  muscles  being 
attached  to  both  fragments,  none  but  a  trifling 
displacement  is  usual.  A  fracture  may  occur 
through  the  surgical  neck.  The  surgical  neck  is 
represented  by  a  narrowed  part  of  the  bone  be- 
hind the  glenoid  fossa,  and  in  the  line  of  the 
suprascapular  notch.  The  smaller  fragment  will, 
therefore,  include  the  coracoid  process,  the  larger, 
the  acromion.  The  amount  of  deformity  in  these 
cases  depends  upon  whether  the  coraco-clavicular 
and  acromio-clavicular  ligaments  are  entire  or 
torn.  If  they  be  torn,  the  smaller  fragment  and 
the  entire  limb  are  displaced  downwards,  and  the 
injury  somewhat  resembles  a  subglenoid  disloca- 
tion.    From  this,  however,  it  is  distinguished  by 


242  THE    UPPER    EXTREMITY  [Chap. 

the  crepitus,  by  the  ease  with  which  the  deformity 
is  removed  and  the  equal  ease  with  which  it  re- 
turns, by  the  position  of  the  head  of  the  humerus 
in  regard  to  the  glenoid  fossa,  and  by  the  con- 
spicuous fact  that  the  coracoid  process  is  displaced 
downwards  with  the  limb._ 

Tumours  of  the  scapula. — Tumours  of  various 
kinds  grow  from  the  scapula  and  mainly  from 
the  spongy  parts  of  the  bone — viz.  the  spine, 
the  neck,  and  the  inferior  angle.  The  bone 
may  be  removed  entire,  with  or  without  am- 
putation of  the  upper  'limb.  An  inter scajiulo- 
thoracic  amputation  is  usually  performed  for 
malignant  tumours  which  involve  structures  in 
the  neighbourhood  of  the  shoulder- joint.  In  this 
operation  the  upper  extremity,  including  the 
scapula  and  the  clavicle  beyond  the  origin  of  the 
sterno-mastoid,  is  removed.  An  elliptical  incision 
is  made  in  front  and  behind  the  shoulder,  the 
upper  end  of  the  ellipse  lying  on  the  clavicle,  the 
lower  at  the  angle  of  the  scapula.  The  operation 
is  commenced  at  the  clavicle  so  as  to  secure  the 
axillary  vessels.  The  artery  is  tied  before  the 
vein  so  that  the  limb  may  continue  to  empty  its 
blood  into  the  circulation.  The  main  vessels  to 
be  noted  in  connexion  withthis  operation  are  the 
suprascapular  at  the  superior  border  of  the  bone, 
the  posterior  scapular  about  the  vertebral  border, 
the  subscapular  running  along  the  lower  border 
of  the  subscapularis  muscle,  the  dorsalis  scapulae 
crossing  the  axillary  edge  of  the  bone,  and  the 
acromial  branches  of  the  acromio-thoracic  artery. 

Ttie  axilla.— The  axilla  may  be  regarded  sur- 
gically as  a  passage  between  the  neck  and  the  upper 
limb  (Fig.  51).  Axillary  tumours  and  abscesses  may 
spread  up  into  the  neck,  and  in  like  manner  cer- 
vical growths  and  purulent  collections  may  extend 
to  the  armpit.  The  skin  forming  the  base  of  the 
axilla  is  provided  with  many  short  hairs  and 
with  numerous  sebaceous  and  sudoriparous  glands. 
In  this  integument  small  superficial  abscesses  are 
often  met  with,   that  arise  usually  from  suppu- 


XI] 


THE    AXILLA 


243 


ration  of  these  glandular  structures,  and  that  are 
brought  about  by  the  friction  of  the  skin  against 
the  clothing.  Owing  to  the  tendency  of  the  axil- 
lary integument  to  become  chafed  and  inflamed 
under  friction,  the  axilla  is  not  a  good  locality  to 
select  for  the  use  of  the  mercurial  inunction  as 
applied  in  syphilis.  Beneath  the  skin  and  super- 
ficial fasciae  is  the  axillary  fascia,  and  beyond  this 


Gt.  Tub. 
Bicip.  Groove 


Fig.  51. — Relationship  of  the  axillary  artery  and  brachial 
plexus  to  the  shoulder-joint  and  axilla. 

membrane  is  the  axillary  space.  The  connective 
tissue  with  which  the  axillary  space  is  mainly 
occupied  is  very  loose,  and,  while  this  laxity 
favours  greatly  the  free  movement  of  the  arm,  it 
at  the  same  time  permits  of  the  formation  of  large 
purulent  collections  and  immense  extravasations 
of  blood. 

It   is   important  to   remember   the    disposition 
of  the    fasciae  about  this  region.     There  are  three 


244  THE    UPPER    EXTREMITY  [Chap. 

layers  principally  concerned.  (1)  The  deep  pec- 
toral fascia  that  covers  in  and  encloses  the  pector- 
alis  major.  (2)  The  clavi-pectoral  fascia  that, 
adherent  above  to  the  clavicle,  fills  in  the  space 
between  that  bone  and  the  pectoralis  minor,  then 
splits  to  invest  this  muscle,  and  joins  the  deep 
pectoral  layer  at  the  anterior  fold  of  the  axilla 
to  form  with  it  the  axillary  fascia.  The  upper 
part  of  this  fascia  is  generally  known  as  the  costo- 
coracoid  me^mbrane.  The  whole  membrane  is  some- 
times'known  also  as  the  "  suspensory  ligament  of 
the  axilla,' ■  since  it  draws  up  the  axillary  fascia 
towards  the  clavicle,  and  is  mainly  instrumental 
in  producing  the  "  hollow  "  of  the  armpit.  (3) 
The  axillary  fascia  that  is  formed  by  the  union  of 
the  two  preceding  fasciae,  and  stretches  across  the 
base  of  the  axilla  from  its  anterior  to  its  posterior 
fold.     It  is  thinnest  under  the  axillary  hairs. 

Abscess  about  the  axillary  region  maybe  formed 
beneath  the  pectoralis  major,  or  betweenthe  two 
pectoral  muscles,  or  beneath  the  pectoralis  minor 
and  clavi-pectoral  fascia,  and  therefore  in  the 
axillary  space.  The  loose  tissue  of  the  axillary 
space  allows  the  formation  of  a  large  abscess 
cavity.  The  abscess  as  it  fills  the  axilla  pushes 
forwards  the  pectoralis  major,  more  or  less  ob- 
literates the  hollow  of  the  armpit,  thrusts  back  the 
scapula,  and  widens  the  angle  between  the  serra- 
fcus  magnus  and  the  subscapularis  muscles.  There 
is  a  great  tendency,  therefore,  for  unrelieved  ab- 
scesses to  extend  upwards  into  the  neck,  that  being 
the  direction  in  which  the  least  amount  of  resist- 
ance is  encountered.  From  the  neck  the  purulent 
collection  may  extend  into  the  mediastinum.  In 
one  case  an  axillary  abscess,  set  up  by  shoulder- 
joint  disease,  perforated  the  first  intercostal  space 
and  set  up  fatal  pleurisy. 

In  opening  an  axillary  abscess,  and,  indeed,  in 
most  incisions  into  this  space,  the  knife  should 
be  entered  at  the  centre  of  the  floor  of  the  axilla, 
i.e.  midway  between  the  anterior  and  posterior 
margins,   and  near  to  the  inner  or  thoracic  side 


XIJ  AXILLARY    LYMPHATICS  245 

of  the  space.  The  vessels  most  likely  to  be  damaged 
by  an  indiscreet  incision  are  the  subscapular, 
running  along  the  lower  border  of  the  subscapu- 
lars muscle;  the  long  thoracic,  following  the 
lower  border  of  the  small  pectoral;  and  the  main 
vessels  lying  close  to  the  humerus.  The  knife,  if 
properly  entered,  should  be  midway  between  the 
two  first-named  vessels,  and  quite  away  from  the 
main  trunks.  There  is  an  artery  (the  external 
mammary)  that  sometimes  comes  off  as  the  lowest 
branch  of  the  axillary  trunk,  and  crosses  the 
middle  of  the  axilla,  to  be  distributed  to  the 
thorax  below  the  long  thoracic.  This  vessel  would 
probably  be  wounded  in  the  incision  above  named. 
The  artery  is,  however,  very  inconstant,  is  small, 
and  is  not  far  below  the  surface.  It  is  usually 
met  with  in  female  subjects. 

Lymphatic  glands  of  the  axilla. — The  axillary 
glands  are  numerous,  and  of  much  surgical  im- 
portance. They  may  be  arranged  in  four  sets 
(1)  The  greater  number  are  placed  to  the  inner 
side  of  the  axillary  vein  beneath  the  axillary  tuft 
of  hair.  This  central  set  of  glands  receives  the 
lymph  from  the  upper  extremity  and  breast.  Pain 
in  the  axilla  which  follows  whitlow  or  any  septic 
infection  of  the  arm  is  due  to  inflammation  of 
this  group,  which  is  pierced  by  the  intercosto- 
humeral  nerve.  (2)  The  deep  axillary  set  lies 
along  the  axillary  vessels.  It  receives  the  lymph 
from  the  central  set  and  becomes  continuous  with 
the  lower  deep  cervical  glands  in  the  subclavian 
triangle  (Fig.  44,  p.  197).  (3)  Other  glands  lie 
upon  the  serratus  magnus  muscle  on  the  thoracic 
side  of  the  axilla,  and  just  behind  the  lower  bor- 
der of  the  pectoral  muscles.  They  receive  ^  the 
lymphatics  from  the  front  of  the  chest,  the  princi- 
pal lymph  vessels  of  the  breast,  and  the  superficial 
lymphatics  of  the  abdomen  as  low  down  as  the 
umbilicus.  Their  efferent  vessels  for  the  most  part 
pass  on  to  join  the  central  set  of  glands.  These 
glands  will  be  the  first  to  be  enlarged  in  certain 
breast  affections,   and  after  blistering  and  other 


246  THE    UPPEE    EXTEEMITY  [Chap. 

superficial  inflammations,  etc.,  of  the  chest  and 
upper  abdomen.  Paulet  has  seen  them  affected 
in  inflammation  of  the  hand.  The  axillary  pro- 
cess of  the  female  breast  is  in  contact  with  this 
set.  (4)  The  remaining  glands  are  situated  at  the 
back  of  the  axilla,  along  the  subscapular  vessels. 
They  are  joined  by  the  lymphatics  from  the  back. 

It  may  here  be  convenient  to  note  that  one  or 
two  glands  are  commonly  found  in  the  groove 
between  the  deltoid  and  pectoralis  major  muscles. 
They  receive  some  vessels  from  the  outer  side  of 
the  arm  and  a  part  of  the  shoulder  and  breast. 
The  superficial  lymphatics  over  the  upper  part  of 
the  deltoid  go  to  the  cervical  glands  (Tillaux), 
over  the  lower  half  to  the  axilla.  The  lymphatics 
from  the  supraspinous  fossa  follow  the  supra- 
scapular artery,  and  join  the  lowest  cervical 
glands.  The  superficial  lymphatics  of  the  back 
that  converge  to  the  axilla  are  derived  from  the 
neck  over  the  trapezius  muscle,  and  from  the 
whole  dorsal  and  lumbar  regions  as  far  down  as 
the  iliac  crest. 

The  complete  removal  of  axillary  glands  is 
an  operation  frequently  undertaken,  especially  in 
cases  of  mammary  cancer.  Free  access  to  them 
is  obtained  by  reflecting  the  pectoral  muscles 
inwards.  It  will  be  understood  from  their  posi- 
tion that  these  bodies,  when  diseased,  are  very 
apt  to  become  adherent  to  the  axillary  vessels, 
and  especially  to  the  vein.  The  latter  vessel  has 
frequently  been  wounded  or  excised  during  the 
removal  of  gland  tumours,  and  in  one  case  at 
least  the  artery  was  accidentally  cut  (Holmes). 

Axillary  vessels. — The  axillary  vein  is  formed 
by  the  union  of  the  basilic  with  the  two  venae 
comites  of  the  brachial  artery.  This  union  com- 
monly takes  place  at  the  lower  border  of  the 
pectoralis  minor  muscle,  and  the  vein  is  therefore 
shorter  than  the  artery.  Sometimes  the  vein  does 
not  exist  as  a  single  trunk  until  just  below  the 
clavicle.  This  condition,  when  it  exists,  is  very 
unfavourable  to  operations  upon  the  artery,   as 


XIj  AXILLARY    VESSELS  247 

many  transverse  branches  cross  that  vessel  to  unite 
the  veins  that  lie  on  either  side  of  it.  The  axil- 
lary vein,  being  comparatively  near  the  heart,  is 
readily  influenced  as  regards  its  contained  blood 
by  the  inspiratory  movement.  Thus  it  happens 
that,  in  many  instances  of  wound  of  the  vessel  or 
of  its  larger  tributaries,  air  has  been  drawn  into 
the  venous  canal  and  death  has  ensued.  The  en- 
trance of  air  into  the  main  vein  is  perhaps  aided 
by  the  circumstance  that  the  costo-coracoid  mem- 
brane (upper  part  of  clavi-pectoral  fascia)  is  ad- 
herent to  the  vessel,  and  thus  tends  to  maintain  it 
in  a  patent  condition  when  wounded.  This  con- 
nexion with  the  fascia  is  supposed  by  some  to 
account  in  part  for  the  furious  bleeding  that 
occurs  from  this  vein  when  it  is  divided. 

The  vein  is  more  often  wounded  than  is  the 
artery,  it  being  larger,  more  superficial,  and  so 
placed  as  to  more  or  less  m  overlap  the  arterial 
trunk.  On  the  other  hand,  in  injury  to  the  vessel 
by  traction,  as,  for  example,  in  reducing  disloca- 
tions, the  artery  suffers  more  frequently  than  the 
vein.  In  all  positions  of  the  upper  limb  the 
artery  keeps  to  the  outer  angle  of  the  axillary 
space.  The  relation  of  the  vein,  however,  to  the 
first  part  of  the  axillary  artery,  the  part  above 
the  pectoralis  minor,  is  modified  by  the  position 
of  the  limb.  Thus,  when  the  arm  hangs  by  the 
side  the  vein  is  to  the  inner  side  of  the  artery, 
and  a  little  in  front  of  it,  but  when  the  limb  is 
at  a  right  angle  with  the  trunk  the  vein  is  drawn 
so  far  in  front  of  the  artery  as  to  almost  entirely 
conceal  that  vessel. 

Aneurysm  is  very  frequent  in  the  axillary 
artery,  a  fact  to  be  explained  by  the  nearness  of 
the  vessel  to  the  heart,  by  the  abrupt  curve  it  pre- 
sents, by  its  susceptibility  to  frequent  and  exten- 
sive movements,  and  by  its  liability  to  share  in  the 
many  lesions  of  the  upper  limb.  In  violent  and 
extreme  movements  of  the  limb  the  artery  may  be 
more  or  less  torn,  especially  if  its  walls  are 
already  diseased. 


248  THE    UPPER    EXTEEMITY  [Chap. 

In  ligaturing  the  first  part  of  the  axillary 
artery  it  is  well  to  note  that  the  pectoralis  major 
has  sometimes  a  cellular  interval  between  two 
planes  of  muscle  fibre,  and  this  may  be  mistaken 
for  the  space  beneath  it  (Heath).  If  the  pector- 
alis minor  has  an  origin  from  the  second  rib,  it 
may  more  or  less  entirely  cover  the  artery  and  re- 
quire division.  The  cord  of  the  brachial  plexus 
nearest  to  the  artery  may  be  mistaken  for  that 
vessel,  or  easily  included  in  a  ligature  intended 
for  it  (Fig.  51).  A  ready  guide  to  the  axillary 
vessels  in  this  operation  is  to  follow  the  cephalic 
vein.  The  anterior  internal  thoracic  nerve  appears 
between  the  vein  and  artery  as  it  passes  to  the 
pectoralis  minor  ;  it  also  may  be  useful  occasionally 
as  a  guide. 

In  applying  a  ligature  to  the  third  part  of  the 
artery,  it  should  be  borne  in  mind  that  a  mus- 
cular slip  sometimes  crosses  the  vessels  obliquely, 
passing  from  the  latissimus  dorsi  to  join  the  pec- 
toralis major,  coraco-brachialis,  or  biceps  mus- 
cles. This  slip  may  give  rise  to  confusion  during 
the  operation,  and  may  be  mistaken  for  the 
coraco-brachialis. 

Brachial  plexus. — When  the  shoulder  is  depressed 
the  upper  and  middle  trunks  of  the  brachial 
plexus,  formed  by  the  fifth,  sixth  and  seventh 
cervical  nerves,  can  be  distinctly  felt  in  the  neck, 
passing  from  beneath  the  posterior  border  of 
the  sterno-mastoid  to  enter  the  axilla  just  ex- 
ternally to  the  mid-point  of  the  clavicle  (Fig.  51). 
The  upper  trunk,  formed  by  the  fifth^  and  sixth 
nerves,  is  by  far  the  most  exposed  to  injury,  for 
the  reason  that  it  rises  higher  in  the  neck  than  the 
middle  and  lower  trunks;  hence  when  the  neck  is 
bent  forcibly  to  the  left,  as  when  a  burden  is 
borne  on  the  right  shoulder,  the  upper  trunk  on 
the  right  side  is  subjected  to  a  greater  strain  than 
the  middle  or  lower  cords.  In  cases  of  shoulder- 
presentation  at  birth,  or  if  the  neck  and  shoulder 
be  forced  apart  by  accident,  the  upper  cord  is  lia- 
ble to  be  strained  or  ruptured,  resulting  in  what  is 


XI]  AXILLARY    NERVES  249 

usually  described  as  Erb's  palsy.  It  will  be  re- 
called that  the  suprascapular,  circumflex,  and 
musculo-cutaneous  nerves  are  derived  from  this 
trunk;  so  are  the  nerves  to  the  rhomboids  and 
serratus  magnus.  The  rupture,  however,  ia  usually 
distal  to  the  origin  of  these  nerves,  and  hence 
their  muscles  escape.  The  muscles  affected  in 
Erb's  palsy  are  the  supraspinatus,  infraspina- 
tus, teres  minor,  deltoid,  coraco-brachialis,  biceps, 
brachialis  anticus,  and  supinator  longus;  occa- 
sionally also  the  supinator  brevis,  extensor  carpi 
radialis  longior,,  and  pronator  radii  teres.  No 
sensory  paralysis  is  observed  in  such  cases.  Curi- 
ously enough,  section  of  the  fifth  cervical  gives 
as  wide  an  area  of  muscular  paralysis  as  section 
of  the  combined  fifth  and  sixth  (W.  Harris).  In 
complete  rupture  of  the  brachial  plexus  sensation 
is  completely  lost  beyond  the  elbow,  but  in  the  arm 
and  shoulder  deep  sensibility  is  retained  (Sher- 
ren).  The  arm,  in  such  lesions,  retains  intact  the 
nerves  received  from  the  descending  cervical  and 
intercosto-humeral. 

Axillary  nerves. — Any  of  the  axillary  nerves 
may  be  injured  by  a  wound,  the  median  being 
the  most  frequently  damaged,  and  the  musculo- 
spiral  the  least  frequently.  The  comparative 
immunity  of  the  latter  is  explained  by  its  deep 
position,  its  situation  at  the  inner  and  posterior 
aspect  of  the  limb,  and  its  large  size.  The  nerves 
are  very  seldom  torn  by  a  traction  on  the  limb 
short  of  more  or  less  complete  avulsion.  Indeed, 
if  forcibly  stretched,  they  are  disposed  rather  to 
become  torn  away  from  their  attachments  to  the 
spinal  cord  than  to  give  way  in  the  axilla.  Thus, 
Flaubert  records  a  case  where  the  last  four  cervi- 
cal nerves  were  torn  away  from  the  cord  during 
a  violent  attempt  to  reduce  a  dislocated  shoulder. 

The  deltoid  region. — This  region,  comprising 
as  it  does  the  "  point  "  of  the  shoulder,  is  limited 
in  all  parts  by  the  deltoid  muscle.  The  deltoid 
covers  the  upper  end  of  the  humerus  and  the 
shoulder-joint  (Fig.   52).     Between  the  joint  and 


250 


THE    UPPEE    EXTREMITY 


[Chap. 


the  surface,  therefore,  are  only  the  skin  and  super- 
ficial fascia,  the  deltoid  in  its  sheath,  and  some 
loose  connective  tissue  (the  subdeltoid  tissue)  in 
which  is  found  the  great  subacromial  bursa.  This 
subdeltoid  tissue  sometimes  assumes  the  form  of  a 
distinct  thick  membrane,  and  may  have  an  im- 
portant influence  upon  the  localization  of  puru- 
lent collections  proceeding  from  the  joint.     The 


PRASPINATUS 


SCAPU 


R0/1I0/1    Proc 
ELTOID 
CAPSULE: 

Bursa 

EPIPHYSEAL  LlttE:'. 


Joimt  Cavity 


Qleaioid  Liqa/^e/it 

Capsule 
st.Circu/mflex  Art. 
Teres  /^Iajor 

Triceps 

Fig.  52. — Section  of  shoulder- joint  to  show  the  relations  of 
the  capsule,  epiphyseal  line,  and  bursa.     {After  Poirier.) 


fatty^  tissue  over  the  deltoid  is  a  favourite  seat 
for  lipomata,  and  it  is  in  this  situation  that  the 
tendency  of  these  growths  to  change  their  position 
is  sometimes  seen.  Thus,  Erichsen  records  a  case 
where  the  tumour  slid  downwards  from  the 
shoulder  to  the  breast. 

Emerging  from  the  interval  between  the  two 
teres  muscles,  and  winding  horizontally  round  the 
shaft  of  the  humerus,  quite  close  to  the  bone,  and 


XIJ  THE    SHOULDER-JOINT  251 

about  the  line  of  the  surgical  neck,  are  the  circum- 
flex nerve  and  posterior  circumflex  artery  (Fig.  51). 
This  nerve  affords  an  example  of  an  arrangement 
pointed  out  by  Mr.  Hilton,  viz.  that  a  principal 
nerve  to  a  joint  not  only  supplies  the  articular 
surfaces,  butalso  some  of  the  main  muscles  that 
move  that  joint,  and  the  skin  over  those  muscles. 
This  nerve  supplies  the  shoulder-joint,  the  deltoid 
and  teres  minor  muscles,  and  the  skin  over  the 
lower  two-thirds  of  the  shoulder  and  upper  part 
of  the  triceps.  It  is  frequently  damaged  in  injuries 
to  the  shoulder,  and  may  be  severely  bruised 
by  a  simple  contusion  of  the  part,  resulting 
in  paralysis  of  the  deltoid.  It  would  appear, 
however,  that  damage  to  the  circumflex  is  much 
less  frequent  after  contusions  of  the  shoulder 
than  was  formerly  maintained.  It  will  also  be 
readily  understood  that  the  nerve  is  often  torn 
in  fractures  of  the  surgical  neck  of  the  humerus, 
in  dislocations  of  that  bone  (especially  the  luxa- 
tion backwards),  and  in  violent  attempts  at 
reducing  such  dislocations  (Fig.  51). 

The  shoulder-joint.— From  one  surgical  point 
of  view,  jointsmay  be  divided  into  (1)  those  that 
depend  for  their  strength  mainly  upon  ligaments ; 
(2)  those  that  are  mechanically  strong,  and  that 
derive  their  stability  to  a  great  extent  from  the 
arrangement  of  their  component  bones;  and  (3) 
those  that  rely  for  their  support  principally  upon 
muscles.  As  an  example  of  the  first  kind  may  be 
cited  the  sterno-clavicular  joint,  of  the  second 
form  the  elbow-joint,  and  of  the  third  the 
shoulder-joint.  ^  The  articulation  the  least  prone 
to  dislocation  is  the  one  that  derives  its  strength 
from  tough  unyielding  ligaments,  while  the  one 
most  often  luxated  belongs  to  the  third  variety,  its 
strength  being  greatly  dependent  upon  muscles 
that  may  be  taken  by  surprise,  and  that  may  them- 
selves, from  disordered  action,  prove  sources  of 
weakness.  These  are,  of  course,  not  the  only  fea- 
tures in  the  etiology  of  dislocation.  A  great  deal 
depends  upon  the  amount  of  movement  permitted 


252  THE    UPPER    EXTREMITY  LChap. 

in  a  given  joint,  and  the  degree  of  leverage  that 
can  be  brought  to  bear  upon  its  parts. 

The  arch  formed  by  the  coracoid  and  acromion 
processes  and  the  ligament  between  them  forms  an 
essential  support  to  the  head  of  the  humerus,  and 
is  an  important  constituent  of  the  articulation. 
With  this  arch  the  humeral  head  is  in  immediate 
relation,  though  not  in  actual  c6ntact  (Fig.  52). 
In  paralysis  of  the  deltoid  the  head  may  be 
separated  by  some  distance  from  the  coracoid 
process,  and  Nannoni  records  the  case  of  a  child 
with  old-standing  paralysis  of  the  deltoid,  between 
whose  humeral  head  and  acromial  vault  four  fin- 
gers could  be  lodged.  It  is  well  to  note  that  at 
least  two-thirds  of  the  head  of  the  bone  are  not 
in  contact  with  the  glenoid  cavity  when  the  arm 
hangs  by  the  side,  and  Anger  points  out  that  in 
this  position  three-fourths  of  the  circumference 
of  the  humeral  head  are  in  front  of  a  vertical  line 
drawn  from  the  anterior  border  of  the  acromion 
process.  In  this  posture,  also,  the  head  is  wholly 
to  the  outer  side  of  the  coracoid  process.  The 
margin  of  the  glenoid  cavity  is  more  prominent 
on  the  inner  than  on  the  outer  side,  while  the 
strongest  part  of  the  margin  and  the  broadest 
part  of  the  fossa  are  below.  This  is  significant, 
since  it  points  to  an  attempt  to  strengthen  a  part 
of  the  joint  that  practice  shows  to  be  the  weakest 
in  the  articulation,  viz.  the  lower  and  inner  por- 
tion of  the  capsule.  It  is  at  this  place  that  the 
head  of  the  bone  leaves  the  joint  in  dislocation  of 
the  shoulder. 

The  capsule  of  the  shoulder-joint  is  very  lax, 
and  would  lodge  a  bone-head  twice  as  large  as  that 
of  the  humerus.  According  to  Henry  Morris,  no 
one  part  of  the  capsule  is  constantly  thicker  than 
the  rest,  as  is  the  case  in  the  hip-joint. 

Of  the  bursas  about  the  joint,  the  subacromial 
bursa  is  the  one  most  frequently  the  seat  of  disease. 
This  sac,  when  distended  with  fluid,  may  be  mis- 
taken for  the  results  of  chronic  inflammation  of 
the  joint  (Fig.  52). 


XIJ  THE    SHOULDER-JOINT  253 

Experiment  shows  that  the  walls  of  this  bursa 
may  be  actually  torn  in  twists  of  the  arm,  especi- 
ally when  either  flexed  or  extended  (Nancrede). 
When  the  sac  is  distended  most  pain  is  elicited  in 
the  position  of  abduction,  for  in  this  posture  the  * 
bursal  walls  are  normally  folded  up,  so  as  to 
form  a  sort  of  collar  in  advance  of  the  greater 
tuberosity.  In  elderly  rheumatic  people  the  sac 
sometimes  communicates  with  the  joint.  The  sub- 
scapular bursa  may  be  regarded  as  an  extension 
of  the  synovial  membrane  of  the  joint  between 
the  terminal  part  of  the  muscle  and  the  scapula. 
Pain  elicited  when  the  arm  is  rotated  at  the 
shoulder-joint  may  be  due  to  disease  in  the  joint, 
in  the  subacromial  or  in  the  subscapular  bursa, 
for  a  movement  then  occurs  in  all  three. 

The  biceps  tendon  strengthens  the  upper  part 
of  the  joint,  keeps  the  humerus  against  the  glen- 
oid cavity  in  the  various  positions  of  the  limb, 
and  prevents  the  head  of  the  bone  from  being 
pulled  too  closely  upwards  under  the  acromion. 
The  tendon  may  be  ruptured,  and  in  such  a  case, 
in  addition  to  the  general  weakening  of  the  limb, 
and  the  peculiar  projection  formed  by  the  con- 
traction of  the  muscle,  the  head  of  the  humerus  is 
usually  drawn  upwards  and  forwards  until  ar- 
rested by  the  coraco-acromial  arch.  Thus,  a  kind 
of  slight  false  dislocation  may  be  produced.  In 
certain  violent  wrenches  of  the  limb  the  tendon 
may  rupture  the  transverse  ligament  which  binds 
it  down,  slip  from  its  groove,  and  be  displaced 
to  one  or  other  side,  usually  to  the  inner  side. 
The  intracapsular  part  of  the  tendon  may  dis- 
appear in  cases  of  chronic  rheumatic  arthritis, 
owing  to  the  friction  against  the  abraded  arti- 
cular surface  of  the  humerus.  In  such  cases  it 
acquires  an  attachment  to  the  bicipital  groove. 

Disease  of  the  shouIder=joint.— This  articulation 
is  liable  to  all  forms  of  joint  disease.  The  capsule, 
as  Just  stated,  is  very  lax,  the  articular  surfaces 
being  kept  in  apposition  by  the  tonus  of  the  sur- 
rounding muscles ;  when  chloroform  is  administered 


254  THE    UPPER    EXTREMITY  [Chap. 

the  surfaces  may  be  freely  separated  and  examined. 
In  joint  disease,  however,  the  effusion  may  effect  a 
considerable  separation  of  the  two  bones.  Braune, 
having  pierced  the  glenoid  cavity  through  the 
supraspinous  fossa,  injected  tallow  at  considerable 
pressure  into  the  joint.  When  fully  distended 
the  humerus  was  found  to  be  separated  from  the 
scapula  by  more  than  \  an  inch,  and  this  may 
serve  to  explain  the  lengthening  of  the  limb  often 
noted  in  joint  disease  of  this  part  with  much 
effusion.  When  the  greatest  degree  of  distension 
of  the  capsule  was  reached  the  humerus  became 
slightly  extended  and  rotated  inwards.  It  is 
significant  that  in  shoulder-joint  disease  it  is  com- 
mon for  the  arm  to  be  found  close  to  the  side,  the 
elbow  carried  a  little  back  (extension),  and  the 
limb  rotated  inwards.  This  position  may  also  be 
due  to  the  rigid  contraction  of  the  muscles  about 
the  joint.  When  such  contractions  exist  it  may 
be  inferred  that  the  powerful  latissimus  dorsi 
has  a  little  advantage  over  its^  opponents,  and 
may  be  answerable  for  the  rotation  in  and  slight 
projection  backwards  of  the  arm.  The  inner  part 
of  the  epiphyseal  cartilage  is  just  within  the 
capsule ;  the  outer,  anterior  and  posterior  parts 
are  entirely  subperiosteal^  It  happens,  therefore; 
that  the  pus  in  suppurative  epiphysitis  will  find 
its  way  into  the  joint. 

There  are  two  diverticula  from  the  synovial 
membrane  :  (1)  one  that  runs  some  way  down  the 
bicipital  groove  with  the  tendon ;  (2)  a  cul-de:sac 
beneath  the  subscapular^  formed  by  a  communica- 
tion between  the  synovial  cavity  and  the  bursa 
under  that  muscle.  When  the  joint  is  filled  with 
effusion,  the  capsule  is  evenly  distended  and  the 
shoulder  evenly  rounded.  Special  projections 
usually  occur  at  the  seats  of  the  diverticula.  Thus 
a  swelling  often  appears  early  in  the  course  of  a 
synovitis  in  the  groove  between  the  #  pectoralis 
major  and  the  deltoid  muscles,  and  this  swelling 
may  appear  bilobed,  being  cut  in  two  by  the 
unyielding  biceps  tendon   (Paulet).     Fluctuation 


XI]         DISLOCATIONS    OF    THE    SHOULDER        255 

can  best  be  felt  by  examining  the  uncovered  part 
of  the  capsule  in  the  axilla  beyond  the  sub- 
scapular muscle.  When  the  joint  suppurates,  pus 
usually  escapes  at  one  of  the  culs-de-sac  just 
mentioned,  most  often  through  the  one  that  fol- 
lows the  biceps  tendon.  Pus  may  thus  extend  for 
some  way  along  the  bicipital  groove.  In  one 
recorded  case,  pus  that  had  escaped  from  the 
shoulder-joint  followed  the  course  of  the  musculo- 
spiral  nerve,  and  opened  on  the  outer  side  of 
the  elbow. 

Dislocations. —  Dislocations  at  this  joint  are 
more  common  than  at  any  other  joint  in  the  body. 
This  is  explained  by  the  shallowness  of  the  glenoid 
fossa,  the  large  size  and  globular  shape  of  the  head 
of  the  humerus,  the  extensive  movements  of  the 
arm,  the  long  leverage  it  affords,  and  the  depend- 
ence of  the  articulation  for  its  strength  mainly 
upon  muscles.  The  upper  limb  and  shoulder  are 
also  peculiarly  exposed  to  injury. 

The  principal  forms  of  luxation  of  the  humerus 
at  the  shoulder  are  :  1.  Subcoracoid,  forwards  and 
a  little  downwards;  the  usual  form.  2.  Sub- 
glenoid, downwards  and  a  little  forwards;  rare. 
3.   Subspinous,  backwards ;  rare. 

In  all  complete  dislocations  the  head  of  the 
bone  leaves  the  joint  cavity  through  a  rent  in 
the  capsule.  In  so-called  "false  luxations"  the 
capsule  is  not  torn.  For  example,  in  the  cadaver, 
if  the  deltoid  be  divided  the  humeral  head  can 
be  displaced  under  the  coracoid  process  without 
rupture  of  the  capsule,  and  the  same  thing  may 
occur  during  life,  in  cases  where  the  muscle  has 
long  been  paralysed. 

In  all  cases  of  dislocation  at  this  joint  the 
primary  displacement  is  always  downwards  into 
the  axilla.  It  is  well  known  that  dislocations  at 
the  shoulder  are  usually  due  to  violence  applied 
to  the  limb  while  the  arm  is  abducted,  or  to  severe 
direct  violence  forcing  the  bone  downwards.  Now, 
when  the  limb  is  abductedthe  head  of  the  humerus 
projects  below  the  glenoid  fossa,    and  rests   and 


256  THE    UPPER    EXTREMITY  [Chap. 

presses  upon  the  inferior  and  least  protected  part 
of  the  capsule.  The  fibres  of  this  portion  of  the 
capsule  being  tightly  stretched  in  this  position, 
it  requires  no  extraordinary  force  to  tear  the 
ligament  and  drive  the  bone  into  the  axilla. 

Thus  it  happens  that  in  luxations  at  this  joint 
the  rent  in  the  capsule  is  at  its  inferior  and  inner 
aspect,  the  humeral  head  lying  beneath  the  sub- 
scapulars, which  is  always  strained  and  some- 
times torn.  The  head  of  the  bone,  being  thus 
driven  downwards  into  the  axilla,  may,  for  cer- 
tain reasons,  remain  there  (subglenoid  form),  or 
more  usually  it  will  be  drawn  forwards  and  in- 
wards by  the  powerful  pectoralis  major,  aided 
by  other  muscles  whose  action  is  now  less  resisted 
and  by  the  weight  of  the  unsupported  limb  (sub- 
coracoid  form) ;  and  lastly,  the  direction  of  the 
violence  being  applied  markedly  from  in  front, 
the  head  of  the  bone  may  be  thrust  backwards 
under  the  acromion  or  spinous  processes  (sub- 
spinous form).  The  overwhelming  frequency  of 
the  subcoracoid  variety  is  explained  by  the  greater 
advantage  at  which  those  muscles  act  that  draw 
the  bone  forwards,  in  comparison  with  those  that 
would  draw  it  backwards,  and  by  the  very  trifling 
opposition  offered  to  the  passage  of  the  head  for- 
wards when  compared  with  the  substantial  ob- 
stacles in  the  way  of  its  passage  backwards  under 
the  scapular  spine. 

Features  common  to  all  dislocations  at  the 
shoulder. — As  the  roundness  of  the  deltoid  depends 
to  a  great  extent  upon  the  presence  beneath 
it  of  the  humeral  head,  and  as  in  all  these 
luxations  (save  perhaps  in  the  slighter  grades  of 
the  subspinous  form)  the  head  is  removed  practi- 
cally from  its  connexion  with  the  deltoid,  that 
muscle^  is  always  more  or  less  flattened.  This 
flattening  is  augmented  by  the  stretching  of  the 
muscle,  which  in  some  degree  is  constantly  pre- 
sent. Stretching  of  the  deltoid  inyolves  abduc- 
tion of  the  arm,  and  this  symptom  is  fairly  con- 
stant in  all  the  luxations.     The  biceps  being  also 


XI]         DISLOCATIONS    OF    THE    SHOULDER        257 

more  or  less  unduly  tense,  the  elbow  is  found 
flexed  and  the  forearm  supinated.  In  every  form 
there  is  some  increase  in  the  vertical  circumfer- 
ence of  the  axilla,  since  the  head,  having  left  the 
glenoid  fossa,  must  occupy  some  part  comprised 
within  that  circumference.  Again,  Dr.  Dugas 
has  pointed  out  that  "  if  the  lingers  of  the  in- 
jured limb  can  be  placed  by  the  patient,  or  by  the 
surgeon,  upon  the  sound  shoulder  while  the  elbow 
touches  the  thorax  (a  condition  that  obtains  in 
the  normal  condition  of  the  joint),  there  can  be 
no  dislocation ;  and  if  this  cannot  be  done  there 
must  be  one,  for  no  injury  other  than  a  disloca- 
tion can  induce  this  physical  impossibility."  This 
depends  upon  the  fact  that  in  consequence  of  the 
rotundity  of  the  thorax  it  is  impossible  for  both 
ends  of  the  humerus  to  touch  it  at  the  same  time, 
and  in  luxation  at  the  shoulder  the  upper  end  of 
the  bone  is  practically  touching  the  trunk.  Lastly, 
from  the  position  of  the  great  vessels  and  nerves 
(Fig.  51)  it  will  be  seen  that  in  the  subcoracoid 
and  subglenoid  luxations  the  head  of  the  bone 
may  press  injuriously  upon  those  structures. 
Thus  may  result  oedema  of  the  limb  and  severe 
pain  or  loss  of  muscular  power.  The  artery  is 
usually  saved  by  its  greater  elasticity ;  but  Berard 
reports  a  case  of  displacement  forwards  where 
the  axillary  artery  was  so  compressed  by  the 
humeral  head  as  to  induce  gangrene  of  the  limb. 
The  close  connexion  of  the  circumflex  nerve  with 
the  humerus  renders  it  #  very  liable  to  injury, 
especially  in  the  subglenoid  and  subspinous  forms 
of  dislocation. 

Special  anatomy  of  each  form  of  shoulder  dis- 
location. 1.  Subcoracoid. — The#  articular  head  of 
the  humerus  lies  on  the  anterior  surface  of  the 
neck  of  the  scapula,  and  the  anatomical  neck 
rests  on  the  anterior  lip  of  the  glenoid  fossa. 
The  head  is  thus  placed  immediately  below  the 
coracoid  process,  and  is  in  front  of,  internal 
to,  and  a  little  below,  its  normal  site.  The 
great  tuberosity   faces  the  empty  glenoid   cavity 


258 


THE    UPPER    EXTREMITY 


[Chap. 


(Fig.  53).  The  subscapulars  muscle  is  stretched 
over  the  head  of  the  humerus,  and  is  usually 
partly  torn.  The  supraspinatus,  infraspinatus, 
and  teres  minor  are  stretched  or  torn,  or  the 
great  tuberosity  may  even  be  wrenched  off.  The 
coraco-brachialis  and  short  head  of  the  biceps  are 
tense,  and  are  immediately  in  front  of  the  head 
of  the  humerus  instead  of  to  its  inner  side.     The 

long  tendon  of 
the  biceps  is  de- 
flected downwards 
and  outwards.  It 
is  sometimes, 
although  rarely, 
torn  from  its 
groove.  The  del- 
t o i  d  is  put 
upon  the  stretch. 
The  prominence 
formed  by  the 
humeral  head  in 
the  front  of  the 
axilla  depends  to 
some  degree  upon 
the  amount  of 
rotation.  If  the 
bone  be  rotated 
out,  the  projection 
is  most  distinct ; 
but  if  rotated^  in, 
its  head  sinks  into 
the  axilla  and  is 
brought  more  in  contact  with  the  scapula  than  with 
the  skin.  The  head  of  the  bone  being  always  carried 
a  little  downwards,  some  lengthening  must  in  all 
cases  really  exist;  but  with  the  ordinary  method 
of  measuring  the  limb  this  lengthening  may  be 
replaced  by  a  normal  measurement,  or  even  by 
apparent  shortening,  if  the  head  of  the  bone  be 
carried  a  good  deal  forwards  and  inwards,  and 
the  limb  be  abducted.  When  the  head  has  left 
the  glenoid  cavity,  abduction  tends  to  bring  the 


Fig.  53. — Subcoracoid  dislocation 
of  the  humerus. 


XI]         DISLOCATIONS    OF    THE    SHOULDER        259 

external  condyle  nearer  to  the  acromion,  and  these 
are  the  two  points  between  which  the  measurement 
is  usually  taken.  Thus  the  apparent  length  of 
the  arm  depends  mainly  upon  the  degree  of  abduc- 
tion of  the  humerus,  or  the  obliquity  of  the  axis 
of  the  bone. 

2.  Subglenoid. — The  head  is  below,  and  a  little 
in  front  of  and  internal  to,  its  normal  position. 
It  cannot  go  directly  downwards,  owing  to  the 
situation  of  the  long  head  of  the  triceps,  but 
escapes  in  the  interval  between  that  muscle  and 
the  subscapularis.  The  articular  surface  of  the 
head  rests  on  the  anterior  aspect  of  the  triangular 
area  just  below  the  glenoid  fossa  that  gives  origin 
to  the  triceps.  The  upper  border  of  the  great 
tuberosity  is  in  close  relation  with  the  lower 
margin  of  the  joint.  The  subscapularis  muscle, 
which  binds  down  the  humeral  head,  is  much 
stretched  or  torn.  The  supraspinatus  and  the 
infraspinatus  are  stretched  or  torn,  and  the  two 
teres  muscles  have  not  been  much  affected  unless 
there  be  considerable  abduction  of  the  arm.  The 
coraco-brachialis  and  biceps  are  stretched,  and 
owing  to  the  amount  of  abduction  usually  present, 
the  biceps  tendon  is  but  little  deflected  from  a 
straight  line. 

3.  Subspinous. — The  head  usually  rests  on  the 
posterior  surface  of  the  neck  of  the  scapula,  the 
groove  of  the  anatomical  neck  of  the  humerus 
corresponding  to  the  posterior  lip  of  the  glenoid 
fossa.  _  The  head  is  thus  placed  beneath  the 
acromion ;  but  it  may  be  displaced  still  farther 
back,  and  may  rest  on  the  dorsum  scapulae,  and 
beneath  the  scapular  spine  (Fig.  54).  The  sub- 
scapularis tendon  is  drawn  right  across  the 
glenoid  fossa,  and  is  often  torn  from  its  attach- 
ment. The  head  pushes  back  the  hinder  part  of 
the  deltoid,  the  infraspinatus  and  teres  minor 
muscles.  These  latter  cover  the  bone,  and  are 
stretched  over  it.  The  great  pectoral  is  rendered 
unduly  tense,  and  this  serves  in  part  to  explain 
the    rotation    inwards    of   the    humerus,    and   the 


260 


THE    UPPER    EXTREMITY 


[Chap. 


abduction  forwards,  that  are  usually  observed, 
those  movements  being  more  or  less  unopposed. 
The  circumflex  nerve  is  often  torn. 

In  reducing  dislocations,  especially  such  as  are 
of  long  standing,  serious  damage  may  be  inflicted 
on  the  axillary  structures.  The  axillary  artery 
suffers  most  frequently,  the  vein  rarely,  and  the 
nerves  still  less  often.  The  artery,  being  placed 
externally,    is   apt   to   contract   adhesions   to   the 

soft  parts  covering  the 
head  of  the  displaced 
bone,  and  therefore 
to  be  torn  when  those 
parts  are  disturbed 
(Fig.  51). 

Fractures  of  the 
upper  end  of  the  hu- 
merus, l.  Anatomical 
neck. — The  upper  part 
of  the  capsule  is  ex- 
actly attached  to  the 
anatomical  neck,  and 
in  this  situation  the 
fracture  may  run 
beyond  the  ligament 
and  be  partly  extra- 
capsular (Fig.  52,  p. 
250).  The  lower  part 
of  the  capsule  is 
inserted  some  little 
way  below  the  ana- 
tomical neck,  and  in  this  position,  therefore,  the 
lesion  must  be  intracapsular.  From  the  line  of 
attachment  of  the  lower  part  of  the  capsule  to 
the  humerus,  fibres  are  reflected  upwards  to  the 
margin  of  the  articular  cartilage  on  the  head  of 
the  bone.  These  fibres,  if  unruptured,  may  serve 
to  connect  the  fragments.  It  is  easy  for  the 
small  and  comparatively  dense  upper  fragment 
to  be  driven  into  the  wide  surface  of  cancellous 
bone  exposed  on  the  upper  surface  of  the  lower 
fragment.     When  impaction  occurs,  there  may  bo 


Fig.  54. — Subspinous  disloca- 
tion of  the  humerus. 


XI]  FRACTURES    OF    THE    HUMERUS  261 

some  flattening  of  the  deltoid,  since  the  head  is 
rendered  of  less  dimensions  by  that  impaction, 
and  consequently  causes  a  less  projection  of  the 
deltoid.  The  difficulty  of  obtaining  crepitus  in 
non-impacted  fractures  will  be  obvious  when  the 
small  size  of  the  upper  fragment  is  considered, 
together  with  its  great  mobility,  and  the  obstacles 
in  the  way  of  so  fixing  it  that  one  broken  end 
may  be  rubbed  against  the  other.  The  diagnosis 
of  such  obscure  cases  is  now  cleared  up  by  the 
aid  of  Rontgen  rays. 

2.  Separation  of  the  upper  epiphysis. — The 
lower  border  of  this  epiphysis  is  represented  by  a 
line  crossing  the  bone  at  the  base  of  the  great 
tuberosity  and  placed  between  the  anatomical 
and  surgical  necks  (see  Fig.  52,  p.  250).  It  would 
be  fairly  indicated  by  a  transverse  saw-cut 
through  the  widest  part  of  the  bone.  The  three 
component  nuclei  of  this  epiphysis  (head,  greater 
and  lesser  tuberosities)  fuse  together  about  the 
fifth  year,  and  the  entire  mass  joins  the  shaft 
about  the  twentieth  year.  The  upper  fragment 
may  be  carried  and  rotated  a  little  outwards  by 
the  muscles  attached  to  the  great  tuberosity,  while 
the  lower  fragment  is  drawn  inwards  and  for- 
wards by  the  muscles  inserted  into  the  bicipital 
groove.  Thus,  a  part  of  the  smooth  upper  end  of 
the  lower  fragment  commonly  forms  a  distinct 
projection  below  the  coracoid  process.  In  such 
case  the  axis  of  the  limb  would  be  altered,  and 
the  elbow  carried  a  little  from  the  side.  Often, 
however,  the  displacement  is  solely  in  the  antero- 
posterior direction,  the  lower  fragment  project- 
ing forwards.  So  wide  are  the  two  bone  surfaces 
at  the  seat  of  injury  that  it  is  scarcely  possible 
for  them  to  overlap  one  another. 

3.  Surgical  neck. — The  surgical  neck  is  situated 
between  the  bases  of  the  tuberosities  and  the  in- 
sertions of  the  latissimus  dorsi  and  teres  major 
muscles.  A  common  displacement  of  parts  is  the 
following.  The  upper  fragment  is  carried  out 
and  rotated  out  by  the  supra-  and  infraspinatus 


262  THE    UPPEE    EXTEEMITY  [Chap. 

and  teres  minor.  The  upper  end  of  the  lower 
fragment  is  drawn  upwards  by  the  deltoid,  biceps} 
coraco-brachialis,  and  triceps,  inwards  by  the 
muscles  attached  to  the  bicipital  groove,  and  for- 
wards by  the  great  pectoral.  Thus  it  forms  a 
projection  in  the  axilla,  and  the  axis  of  the  limb 
is  altered  so  that  the  elbow  projects  from  the  side. 
This  displacement,  however,  is  by  no  means  con- 
stant. Pean,  Anger,  and  others  maintain  that  the 
usual  deformity  is  a  projection  of  the  upper  end 
of  the  lower  fragment  forwards,  and  that  this 
deviation  is  due  to  the  nature  and  direction  of 
the  violence,  and  not  to  muscular  action.  In  some 
cases  there  is  no  displacement,  the  broken  ends 
being  retained  in  situ,  probably,  by  the  biceps 
tendon  and  the  long  head  of  the  triceps.  In  at 
least  one  instance  (Jarjavay)  the  lower  fragment 
was  so  drawn  upwards  and  outwards,  apparently 
by  the  deltoid,  as  to  nearly  pierce  the  skin  of  the 
shoulder.  Hamilton  comes  to  the  general  con- 
clusion "  that  complete  or  sensible  displacement 
is  less  common  at  this  fracture  than  in  most  other 
fractures/ '  and  in  this  conclusion  many  surgeons 
agree. 

Amputation  at  the  shoulder-joint. — The  deltoid 
muscle  forms  an  ideal  amputation  flap.  It  has 
its  blood  and  nerve  supply  secured  for  it  by  the 
posterior  circumflex  vessels  and  circumflex  nerve, 
which  require  to  be  avoided  as  the  flap  is  raised 
from  the  posterior  aspect  of  the  upper  extremity 
of  the  humerus  prior  to  division  of  the  capsule. 
The  coracoid  process  lies  under  the  anterior  border 
of  the  muscle,  and  immediately  externa^  to  the 
line  of  the  axillary  vessels.  Thence  the  preliminary 
incision,  which  commences  just  externally  to  the 
coracoid,  and  is  carried  down  the  arm  along  the 
anterior  border  of  the  muscle,  gives  access  to  the 
axillary  vessels  so  that  they  may  be  secured  below 
the  origin  of  the  posterior  circumflex  and  above 
the  origin  of#  the  superior  profunda.  The  in- 
cision is  carried  backwards  above  the  insertion 
of  the  deltoid  to  the  humerus.     The  insertion  of 


XI J         AMPUTATION    AT    SHOULDEE- JOINT        263 

the  pectoralis  major  is  cut  in  the  incision  along 
the  anterior  border  of  the  deltoid;  so  are  the 
latissimus  dorsi  and  teres  major.  The  insertions 
of  the  teres  minor,  infraspinatus,  supraspinatus 
and  subscapularis  are  adherent  to  the  capsule 
and  are  cut  through  with  it,  so  as  to  free  the 
head  of  the  bone.  The  lower  part  of  the  capsule 
and  the  long  head  of  the  triceps  are  severed  after 
the  head  of  the  humerus  has  been  raised  from 
its  socket  through  the  upper  wound. 


CHAPTER    XII 

THE    ARM 

The  arm,  upper  arm,  or  brachial  region  is  con- 
sidered to  extend  from  the  axilla  above  to  the 
region  of  the  elbow  below. 

Surface  anatomy. — In  women,  and  in  those 
who  are  fat,  the  outline  of  the  arm  is  rounded 
and  fairly  regular.  It  is  less  regular  in  the  mus- 
cular, in  whom  it  may  be  represented  by  a 
cylinder,  somewhat  flattened  on  either  side  and 
unduly  prominent  in  front  (biceps  muscle).  The 
outline  of  the  biceps  muscle  is  distinct,  and  on 
either  side  of  it  is  a  groove.  The  inner  of  the 
two  grooves  is  by  far  the  more  conspicuous.  It 
runs  from  the  bend  of  the  elbow  to  the  axilla,  and 
indicates  generally  the  position  of  the  basilic  vein 
and  brachial  artery.  The  outer  groove  is  shal- 
low, and  ends  above  at  the  insertion  of  the  deltoid 
muscle.  So  far  as  it  goes  it  marks  the  position 
of  the  cephalic  vein. 

The  insertion  of  the  deltoid  is  an  important 
landmark,  and  can  be  easily  distinguished.  It 
indicates  very  precisely  the  middle  of  the  shaft 
of  the  humerus,  is  on  the  same  level  with  the  in- 
sertion of  the  coraco-brachialis  muscle,  and  marks 
the  upper  limit  of  the  brachialis  anticus.  It 
corresponds  also  to  the  spot  where  the  cylindrical 
part  of  the  humeral  shaft  joins  the  prismatic 
portion,  to  the  point  of  entrance  of  the  nutrient 
artery,  and  to  the  level  at  which  the  musculo- 
264 


Chap.  XII]     SURFACE    ANATOMY    OF    ARM  265 

spiral  nerve  and  superior  profunda  artery  cross 
the  back  of  the  bone. 

When  the  arm  is  extended  and  supiinated,  the 
brachial  artery  corresponds  to  a  line  drawn  along 
the  inner  border  of  the  biceps,  from  the  outlet  of 
the  axilla  (at  the  junction  of  its  middle  and  an- 
terior thirds)  to  the  middle  of  the  bend  of  the 
elbow.  The  artery  is  superficial,  and  can  be  felt 
in  its  entire  extent.  In  its  upper  two-thirds  it 
lies  on  the  inner  aspect  of  the  shaft  of  the 
humerus,  and  can  be  compressed  against  the  bone 
by  pressure  in  a  direction  outwards  and  slightly 
backwards.  In  its  lower  third  the  humerus  lies 
behind  it,  and  compression,  to  be  effectual,  should 
be  directed  backwards. 

The  inferior  profunda  would  be  represented 
by  a  line  drawn  from  the  inner  side  of  the 
humeral  shaft  at  its  middle  to  the  back  part  of 
the  internal  condyle.  The  nutrient  artery  enters 
the  bone  at  its  inner  aspect  opposite  the  deltoid 
insertion,  and  the  anastomotic  vessel  comes  off 
about  2  inches  above  the  bend  of  the  elbow. 

The  ulnar  nerve  follows  first  the#  brachial 
artery,  and  then  a  line  drawn  from  the  inner  side 
of  that  vessel,  about  the  level  of  the  insertion  of 
the  coraco-brachialis,  to  the  gap  between  the  inner 
condyle  and  the  olecranon.  The  main  part  of  the 
internal  cutaneous  nerve  is  beneath  the  inner 
bicipital  groove,  while  the  musculo-cutaneous 
nerve  becomes  superficial  in  the  bend  of  the  elbow 
at  the  outer  margin  of  the  tendon  of  the  biceps. 

The  skin  of  the  arm  is  thin  and  smooth, 
especially  in  front  and  at  the  sides.  It  is 
very  mobile,  being  but  loosely  attached  to  the 
deeper  parts  by  a  lax  subcutaneous  fascia.  In 
circular  amputations  of  the  arm  this  looseness  of 
the  integument  allows  it  to  be  sufficient^  drawn 
up  by  traction  with  the  hand  only.  It  is  from 
the  integument  covering  the  anterior  surface  of 
the  biceps  that  the  flap  is  fashioned  in  Taglia- 
cozzi's  operation  for  the  restoration  of  the  nose. 
The  fineness  of  the  skin  of  this  part,  and  its 
J* 


266  THE    UPPER    EXTREMITY  [Chap. 

freedom  from  hairs,  render  it  very  suitable  for 
this  procedure.  The  scanty  attachments  of  the  skin 
of  the  arm  allow  it  to  be  readily  torn  or  stripped 
away  in  lacerated  and  contused  wounds.  Some- 
times in  these  lesions  large  flaps  of  integument 
are  violently  dissected  up.  The  looseness  of  the 
subcutaneous  tissues  favours  greatly  the  spread 
of  inflammatory  processes,  while  its  comparative 
thinness  allows  of  the  early  manifestation  of 
ecchymoses. 

The  limb  is  completely  invested  with  a  deep 
fascia,  the  brachial  aponeurosis,  as  by  a  sleeve. 
The  fascia  is  held  down  at  the  sides  by  the  two 
intermuscular  septa  which  are  attached  along  the 
outer  and  inner  margins  of  the  humerus,  running 
from  the  deltoid  insertion  to  the  outer  condyle  on 
the  one  side,  and  from  the  coraco-brachialis  inser- 
tion to  the  inner  condyle  on  the  other.  By  means 
of  this  aponeurosis  and  its  septa  the  arm  is 
divided  into  two  compartments,  that  can  be  well 
seen  in  transverse  sections  of  the  limb  (Fig.  55, 
p.  270).  These  compartments  serve  to  confine  in- 
flammatory and  hemorrhagic  effusions.  The  an- 
terior of  the  two  spaces  has  the  less  substantial 
boundaries,  owing  to  the  thinness  of  the  brachial 
fascia  as  it  covers  the  biceps.  Effusions  can 
readily  pass  from  one  compartment  to  the  other 
by  following  the  course  of  those  structures  that, 
by  piercing  the  intermuscular  septa,  are  common 
to  both  spaces.  These  are  the  musculo-spiral  and 
ulnar  nerves,  the  superior  and  inferior  profunda, 
and  anastomotic  arteries.  The  principal  struc- 
tures that  pierce  the  brachial  aponeurosis  itself 
are  the  basilic  vein,  a  little  below  the  middle  of 
the  arm,  the  internal  cutaneous  nerve,  about  the 
middle,  and  the  external  cutaneous  nerve,  at  the 
elbow.  The  two  first-named  are  in  the  inner 
bicipital  groove,  and  the  last-named  in  the  outer. 

The  brachialis  anticus  is  closely  adherent  to 
the  bone,  while  the  biceps  is  free.  It  follows, 
therefore,  that  in  section  of  these  muscles,  as  in 
amputation,  the  latter  muscle  retracts  more  con- 


XII]  BRACHIAL    ARTERY  267 

siderably  than  does  tho  former.  It  is  well,  there- 
fore, in  performing  a  circular  amputation,  to 
divide  the  biceps  muscle  first,  and  then,  after  it 
has  retracted,  to  cut  the  brachialis  anticus. 

Brachial  artery. — The  line  of  this  vessel 
has  already  been  given.  It  is  well  to  note  that 
in  the  very  muscular  the  artery  may  be  over- 
lapped to  a  considerable  extent  by  the  biceps 
muscle.  Compression  of  the  brachial,  unless  per- 
formed carefully  with  the  fingers,  can  hardly 
avoid  at  the  same  time  compression  of  the  median 
nerve.  It  must  also  be  remembered  that  the  in- 
ternal cutaneous  nerve  lies  in  front  of  the  vessel, 
or  close  to  its  inner  side,  until  it  pierces  the 
fascia;  that  the  ulnar  nerve  lies  along  the  inner 
side  of  the  artery  as  far  as  the  coraco-brachialis 
insertion ;  and  that  behind  the  commencement  of 
the  vessel  is  the  musculo-spiral  nerve.  The  vense 
comites  are  placed  one  on  either  side  of  the  artery, 
and  communicate  frequently  with  one  another  by 
short  transverse  branches  which  directly  crossthe 
vessel,  and  which  may  give  trouble  in  operations 
upon  the  artery.  If  in  ligaturing  the  artery  at 
its  middle  third  the  arm  rests  upon  any  support, 
the  triceps  may  be  pushed  up  and  mistaken  for 
the  biceps.  If  the  incisions  be  too  much  to  the 
inner  side  the  basilic  vein  may  be  cut,  or  the 
ulnar  nerve  exposed  and  mistaken  for  the  median. 
Tillaux  states  that  in  the  operation  a  large  in- 
ferior profunda  artery  has  been  taken  for  the 
brachial.  Inasmuch  as  the  median  nerve  often 
derives  distinct  pulsation  from  the  subjacent  ves- 
sel, it  happens  that  in  the  living  subject  it  has 
been  confused  with  the  main  artery  itself. 

Abnormalities  in  the  arrangement  of  the  bra- 
chial artery  are  so  frequent  (they  occur  in  12 
to  15  per  cent,  of  arms)  as  to  be  of  surgical  im- 
portance. It  is  not  unusual  to  find  a  collateral 
branch  (vas  aberrans)  arising  from  the  upper 
part  of  the  brachial  or  lower  part  of  the  axillary, 
passing  down  the  arm,  superficially  to  the  median 
nerve,  and  ending  in  the  radial  or  sometimes  the 


268  THE    UPPER    EXTREMITY  LChcip. 

ulnar  artery.  The  vas  aberrans  may  replace  the 
brachial,  in  which  case  the  artery  will  be  found 
superficial  instead  of  deep  to  the  median  nerve, 
and  the  profunda  vessels  arise  from  the  remnant 
of  the  real  brachial  artery.  This  superficial 
brachial  vessel  may  pass  under  the  supra- 
condyloid  process,  a  hooked  projection  of  bone 
which  occasionally  springs  from  the  humerus,  2 
inches  above  the  epicondyle.  It  is  situated 
amongst  the  inner  fibres  of  origin  of  the  brachialis 
anticus. 

The  musculo-spiral  nerve,  from  its  close 
contact  with  the  bone,  which  it  crosses  at  the  level 
of  the  deltoid  insertion,  is  frequently  injured  and 
torn.  Thus  it  has  been  damaged  in  severe  con- 
tusions, in  kicks,  in  stabs,  in  bites  from  horses, 
and  very  frequently  in  fractures  of  the  humeral 
shaft;  or  the  nerve  may  be  sound  at  the  time  of 
fracture,  and  become  subsequently  so  involved 
in  callus  as  to  lead  to  paralysis  of  the  parts 
it  supplies.  In  a  case  reported  by  Tillaux, 
where  paralysis  followed  some  time  after  a  frac- 
ture, the  nerve  was  found  embedded  in  callus,  and 
on  cutting  some  of  the  redundant  mass  away  a 
good  recovery  followed.  In  several  instances  the 
nerve  has  been  paralysed  by  the  pressure  of  the 
head  when  a  man  has  slept  with  his  head  resting 
on  the  arm  in  the  position  of  full  supination  and 
abduction.  It  is  said  to  be  often  paralysed  in 
Russian  coachmen  who  fall  asleep  with  the  reins 
wound  round  the  upper  arm.  It  has  also  been 
frequently  damaged  by  the  pressure  of  badly  con- 
structed crutches,  especially  those  that  afford  no 
proper  support  for  the  hand.  Indeed,  it  is  the 
nerve  most  often  affected  in  "  crutch  paralysis,' ' 
the  ulnar  being  the  trunk  that  suffers  next  in 
frequency. 

Fracture  of  the  shaft  of  the  humerus  is 
usually  due  to  direct  ^  violence.  The  shaft  may, 
however,  be  broken  by  indirect  violence,  and  of  all 
bones  the  humerus  is  said  to  be  the  one  most 
frequently  fractured  by  muscular  action.     As  ex- 


XII]  FRACTURE    OF    THE    HUMERUS  269 

amples  of  the  latter  may  be  noted  the  throwing 
of  a  ball,  the  clutching  at  a  support  to  prevent  a 
fall,  and  the  so-called  trial  of  strength  known  as 
"  wrist-turning.' '  When  the  bone  is  broken  above 
the  deltoid  insertion  the  lower  fragment  may  be 
drawn  upwards  by  the  biceps,  triceps,  and  del- 
toid, and  outwards  by  the  last-named  muscle; 
while  the  upper  fragment  is  drawn  inwards  by  the 
muscles  attached  to  the  bicipital  groove.  When 
the  fracture  is  below  the  deltoid  insertion,  the 
lower  end  of  the  upper  fragment  may  be  carried 
outwards  by  that  muscle,  while  the  lower  frag- 
ment is  drawn  upwards  to  its  inner  side  by  the 
biceps  and  triceps.  The  deformity,  however,  as 
a  rule  depends  much  more  upon  the  nature  and 
direction  of  the  force  that  breaks  the  bone  than 
upon  any  muscular  action.  The  displacements 
just  noted  may  be  met  with,  but  usually  they  are 
quite  independent  of  the  relation  of  the  deltoid 
insertion  to  the  seat  of  fracture,  and  cannot  be 
tabulated.  The  weight  of  the  arm  seldom  allows 
of  more  than  f  of  an  inch  of  shortening. 

The  humerus  is  more  frequently  the  seat  of 
non-union  after  fracture  than  is  any  other  bone. 
This  result  is  quite  independent  of  the  position 
of  the  fracture  in  relation  to  the  nutrient  artery. 
Hamilton's  explanation  is  briefly  this  :  The  frac- 
ture is  usually  so  adjusted  that  the  elbow  is 
flexed;  this  joint  soon  becomes  fixed  by  muscular 
rigidity,  and  when  any  movement  is  made  as  if 
to  flex  or  extend  the  forearm  on  the  arm,  that 
movement  no  longer  occurs  at  the  elbow- joint,  but 
at  the  seat  of  fracture.  Thus,  if  the  arm  be  in 
a  sling,  and  the  patient  allows  the  hand  to  drop 
by  relaxing  that  sling,  it  is  maintained  that  the 
bulk  of  that  movement  will  take  place  about  the 
fracture  line.  There  are  many  objections  to  this 
theory.  If  true,  the  tendency  to  movement  about 
the  fragments  would  be  the  greater  the  farther 
the  fracture  is  from  the  elbow- joint,  but  non- 
union is  more  common  at  the  middle  than  at  the 
upper  third  of  the  shaft.     Probably  many  causes 


270 


THE    UPFER    EXTREMITY 


[Chap. 


conspire  to  bring  about  non-union  of  fractures 
of  this  bone,  among  which  may  be  mentioned  the 
imperfect  fixing  of  the  joint  above  the  fracture, 
and  the  inadequate  support  afforded  to  the  elbow, 
whereby  the  weight  of  the  arm  and  of  the  splints 
tends  to  drag  the  lower  fragment  out  of  the 
proper  line  it  should  form  with  the  upper  frag- 
ment.    The  most  effective  cause  would  appear  to 

be  the  entangle- 
ment of  muscular 
tissue  between  the 
broken  ends,  for 
it  must  be  re- 
membered that 
the  shaft  of  the 
bone  is  closely 
surrounded  by 
muscular  fibres 
that  are  directly 
adherent  to  its 
surfaces.  Thus, 
in  an  oblique 
fracture  the  end 
of  one  fragment 
may  be  driven 
into  the  brachia- 
lis  anticus,  while 
the  other  end 
projects  into  the 
substance  of  the 
triceps,  and  im- 
mediate contact  of  the  bones  may  be  consequently 
prevented. 

Amputation  through  the  middle  of  the 
arm.— The  parts  divided  in  a  circular  amputation 
are  fully  shown  in  Fig.  55.  In  the  flap  method 
there  is  a  danger  of  transfixing  the  brachial 
artery.  The  artery,  as  may  be  seen  from  Fig.  55, 
may  be  pushed  forwards  or  backwards  by^  pres- 
sure applied  to  the  muscles  between  which  it 
lies.  Before  the  flaps  are  shaped,  the  vessels  may 
be    secured    at    the    inner    border    of    the    biceps. 


Fig.  55. — Transverse  section  through 
the  middle  of  the  arm.     {Braune.) 

a,  Biceps  ;  b,  coraco-brachialis  ;  c,  brachialis 
anticus  ;  d,  triceps  ;  1,  brachial  artery  ; 
2,  median  nerve ;  3,  ulnar  nerve  ;  4, 
musculo-spiral  nerve. 


XII]  AMPUTATION    OF    THE    AEM  271 

In  the  anterior  flap  are  included  the  biceps, 
the  greater  part  of  the  brachialis  anticus,  with 
the  musculo-cutaneous  nerve  between  them,  and 
a  small  piece  of  the  triceps  from  the  inner  side 
of  the  limb.  In  the  posterior  flap  are  the  triceps, 
any  small  part  of  the  outer  portion  of  the 
brachialis  not  included  in  the  anterior  flap,  the 
superior  profunda  artery,  and  the  musculo-spiral 
nerve. 


CHAPTER   XIII 

THE   REGION   OF   THE   ELBOW 

Surface  anatomy. — On  the  anterior  aspect  of 
the  elbow  are  seen  three  muscular  elevations. 
One,  above  and  in  the  centre,  corresponds  to  the 
biceps  and  its  tendon ;  while,  of  the  two  below  and 
at  the  sides,  the  outer  corresponds  to  the  supina- 
tor longus  and  the  common  extensor  mass,  and  the 
inner  to  the  pronator  radii  teres  and  the  common 
set  of  flexor  muscles.  The  arrangement  of  these 
elevations  is  such  that  two  grooves  are  formed, 
one  on  either  side  of  the  biceps  and  its  tendon. 
The  grooves  diverge  above,  and  join  the  outer  and 
inner  bicipital  grooves,  while  below  they  meet 
over  the  most  prominent  part  of  the  tendon,  and 
thus  form  together  a  V-shaped  depression  (Fig. 
56).  The  distinctness  of  these  details  depends 
upon  the  thinness  and  muscular  development  of 
the  individual.  In  the  inner  of  the  two  grooves 
are  to  be  found  the  median  nerve,  the  brachial 
artery  and  its  veins;  while  deeply  placed  below 
the  outer  groove  are  the  terminations  of  the  mus- 
culo-spiral  nerve  and  superior  profunda  artery, 
with  the  small  radial  recurrent  vessel.  The  biceps 
tendon  can  generally  be  felt  distinctly.  Its  outer 
border  is  more  evident  than  is  its  inner  edge, 
owing  to  the  connexion  of  the  bicipital  fascia 
with  the  latter  side  of  the  tendon.  Extending 
transversely  across  the  front  of  this  region  is 
a  crease  in  the  integument,  the  "  fold  of  the 
elbow. "  This  fold  is  not  a  straight  line,  but  is 
272  - 


Chap.  XIII]      REGION    OF    THE    ELBOW  273 

convex  below.  It  is  placed  some  little  way  above 
the  line  of  the  articulation,  and  its  lateral  ter- 
minations correspond  to  the  tips  of  the  two  con- 
dylar eminences.  In  backward  dislocations  of  the 
elbow  the  lovwer  end  of  the  humerus  appears  about 
1  inch  below  this  fold,  whereas  in  a  fracture  of 
the  humerus  just  above  the  condyles  the  fold  is 
either  opposite  to  the  prominence  formed  by  the 
lower  end  of  the  upper  fragment,  or  is  below  it. 
This  crease  is  obliterated  on  extension. 

At  the  apex  of  the  V-shaped  depression,  about 
the  spot  where  the  biceps  tendon  ceases  to  be  dis- 
tinctly felt,  and  at  the  outer  side  of  that  tendon, 
the  median  vein  divides  into  the  median  basilic 
and  the  median  cephalic.  At  the  same  spot  also 
the  deep  median  vein  joins  the  superficial  vessels. 
The  median  basilic  vein  can  be  seen  to  cross  the 
biceps  tendon,  to  follow  more  or  less  closely  the 
groove  along  the  inner  border  of  the  muscle,  and 
to  join,  a  little  above  the  internal  condyle,  with 
the  posterior  ulnar  vein  to  form  the  basilic  trunk. 
The  median  cephalic,  following  the  groove  at  the 
outer  margin  of  the  biceps,  joins,  about  the  level 
of  the  external  condyle,  with  the  radial  vein  to 
form  the  cephalic  vein.  The  brachial  artery 
bifurcates  1  inch  below  the  centre  of  a  line  drawn 
from^  one  condyle  to  the  other;  the  point  of 
division  is  opposite  the  neck  of  the  radius.  "  The 
coronoid  process  of  the  ulna  can  be  indistinctly 
felt,  if  firm  pressure  is  made  in  the  triangular 
space  in  front  of  the  joint  "  (Chiene).  The  points 
of  the  two  condyles  can  always  be  felt.  The  in- 
ternal condyle  is  the  more  prominent  and  the  less 
rounded  of  the  two.  The  humero-radial  articula- 
tion is  in  a  horizontal  Jine,  but  the  humero-ulnar 
joint  is  oblique,  the  joint  surfaces  sloping  down- 
wards and  inwards.  Thus  it  happens  that  while 
the  external  condyle  is  only  f  of  an  inch  (18  mm.) 
above  the  articular  line,  the  point  of  the  internal 
condyle  is  more  than  1  inch  (28  mm.)  above  that 
part  (Paulet).  From  the  obliquity  of  the  joint 
surfaces  between  the  ulna  and  humerus,  it  follows 


274  THE    UPPER    EXTREMITY  [Chap. 

that  the  forearm,  when  in  extension,  is  not  in  a 
straight  line  with  the  upper  arm,  but  forms  with 
it  an  angle  that  opens  outwards.  Thus,  when 
traction  is  made  upon  the  entire  upper  limb  from 
the  wrist,  some  of  the  extending  force  is  neces- 
sarily lost,  and  such  traction,  therefore,  should 
be  applied  from  the  elbow,  as  is  the  usual  practice 
in  reducing  a  dislocation  of  the  shoulder  by 
manipulation.  A  line  drawn  through  the  two 
condyles  will  be  at  right  angles  with  the  axis  of 
the  upper  arm?>  while  it ^  will  form  externally  a 
smaller  angle  with  the  axis  of  the  forearm.  Thus, 
if  we  look  at  the  upper  arm,  the  two  condyles  are 
on  the  same  level,  whereas,  when  viewed  from  the 
forearm,  the  inner  condyle  lies  at  a  higher  level 
than  does  the  external  process. 

The  joint  line  of  the  elbow  is  equivalent  only 
to  about  two-thirds  of  the  width  of  the  entire  line 
between  the  points  of  the  two  condyles  (Fig.  58, 
p.  287).  The  prominence  of  the  condyles  forms  a 
capital  point  d'appui  for  traction  by  encircling 
bands  applied  to  the  limb  above  the  elbow-joint. 
At  the  back  of  the  elbow  the  prominence  of  the 
olecranon  is  always  to  be  distinctly  felt.  It  lies 
nearer  the  internal  than  the  external  condyle.  In 
extreme  extension  the  summit  of  the  olecranon 
is  a  little  above  the  line  joining  the  two  condyles. 
When  the  forearm  is  at  right  angles  with  the  arm, 
the  tip  of  the  process  is  below  the  line  of  the 
condyles,  and  in^  extreme  flexion  it  lies  wholly 
in  front  of  that  line.  Between  the  olecranon  and 
the  inner  condyle  is  a  depression  that  lodges  the 
ulnar  nerve  and  the  posterior  ulnar  recurrent 
artery. 

To  the  outer  side  of  the  olecranon,  and  just 
below  the^  external  condyle,  there  is  a  depression 
in  the  skin  which  is^  very  obvious  when  the  limb 
is  extended.  This  pit  is  to  be  seen  even  in  those 
who  are  fat,  and  also  in  young  children.  In  it 
the  head  of  the  radius  and  radio -humeral  joint 
can  be  felt,  and  can  be  well  distinguished  when 
the  bone  5s  rotated  in  pronation  and  supination. 


XIII 1 


SKIN    OF    THE    ELBOW 


275 


The  pit  corresponds  to  the  hollow  between  the 
outer  border  of  the  anconeus  and  the  muscular 
eminence  formed  by  the 
two  radial  extensors  of  the 
carpus  and  the  supinator 
longus.  The  highest  point 
of  the  bone  that  can  be 
felt  moving  on  rotation 
will  correspond  to  the 
radius  immediately  below 
the  line  of  the  elbow- 
joint,  and  is  a  valuable 
guide  to  that  articulation. 
The  upper  limit  of  the 
elbow-joint  reaches  a  line 
drawn  between  the  point 
of  the  two  condyles.  The 
tubercle  of  the  radius  can 
be  felt  just  below  the  head 
of  the  bone  when  the  limb 
is  in  the  position  of  ex- 
treme pronation. 

The  skin  in  front  of 
the  elbow  m  is  thin  and 
fine,  and  is  ^  readily  ex- 
coriated by  tight  bandag- 
ing   and    by    improperly   Fig.  56.-Left  elbow  from 

in  front. 


applied  splints.  The  thin- 
ness of  the  skin  allows 
the ^  subjacent  veins  to  be 
easily  seen  through  the 
integuments,  but  the  dis- 
tinctness with  which  these 
veins  appear  depends 
mainly  upon  the  amount 
of  subcutaneous  fat.  In 
the  very  stout  they  may 
be  quite  invisible,  and  it 
may  be  difficult  or  im- 
possible to  render  them  evident  by  the  usual 
means  adopted  in  venesection.  Tillaux  points 
out  that  if  such  people  are  bled  a  pellet  of  fat 


a,  Basilic  vein  ;  b,  cephalic  vein  ; 
c,  on  the  ulna  points  to 
median  basilic  vein  ;  d,  on 
the  radius  points  to  median 
cephalic  vein ;  e,  radial 
vein  ;/,  median  vein  ;  g,  pos- 
terior ulnar  vein.  The  bra- 
chial artery  passes  behind 
the  median-basilic  vein, 
and  divides  into  its  radial 
aud  ulnar  branches  to  the 
inner  side  of  the  radial 
neck. 


276  THE    UPPER    EXTREMITY  [Chap. 

will  often  project  into  the  wound  and  prevent 
the  flow  of  blood. 

The  arrangement  of  the  superficial  veins  in 

front  of  the  elbow,  so  as  to  form  an  M-shaped 
figure,  is  familiar,  but  it  must  be  confessed  that 
it  is  by  no  means  constant  (Fig.  56).  So  far  as  I 
have  seen,  it  would  appear  that  the  precise  M-like 
arrangement  figured  in  most  books  is  only  present 
in  about  two-thirds,  and  perhaps  in  only  one- 
half,  of  all  cases. 

The  median  vein  breaks  up  into  the  median 
cephalic  and  median  basilic,  just  to  the  outer 
side  of  the  biceps  tendon,  and,  therefore,  the 
latter  vein  passes  in  front  of  the  tendon,  of  the 
brachial  artery  and  its  veins,  and  of  the  median 
nerve.  From  these  structures  it  is  separated  by 
the  bicipital  fascia.  The  median  basilic  vein  may 
cross  the  brachial  artery  abruptly,  and  be  com- 
paratively free  of  it,  except  at  the  point  of  cross- 
ing, or  it  may  run  for  some  distance  quite  in 
front  of  the  artery,  or,  crossing  it  early,  it  may 
lie  parallel  with  the  vessel,  although  at  a  different 
level,  for  the  greater  part  of  its  course.  As  re- 
gards size,  the  median  basilic  is  usually  the 
largest  of  these  Veins,  the  median  cephalic  coming 
next,  and  the  median  itself  third,  while  the  ulnar 
and  radial  veins  are  the  smallest  of  the  series. 
These  veins  are  liable  to  many  abnormalities, 
some  of  the  most  conspicuous  being  in  cases  where 
the  main  arteries  of  the  part  also  are  abnormal. 
The  deviation  is  more  usual  in  the  veins  on  the 
radial  than  in  those  on  the  ulnar  side  of  the  limb. 
Thus  it  is  common  for  the  radial  or  the  median 
cephalic  veins,  or  both,  to  be  either  very  defec- 
tive or  entirely  absent.  In  spite  of  the  relation 
the  median  basilic  vein  bears  to  the  brachial 
artery,  it  is  nevertheless  the  vein  usually  selected 
in  venesection  and  transfusion.  The  reasons  for 
its  selection  are  these  :  it  is  usually  the  largest 
and  most  prominent  of  the  veins,  and  the  one 
the  nearest  to  the  surface;  it  is  also  the  least 
movable  vein,    and  the   one   the   least  subject  to 


XIII]  VEINS    OF    THE    ELBOW  277 

variation.  The  bicipital  fascia  forms  an  excel- 
lent protection  to  the  brachial  artery  during 
phlebotomy.  The  density  of  that  membrane 
varies,  and  depends  mainly  upon  the  degree  of 
muscular  development.  In  thin  subjects  the 
median  basilic  vein  may  receive  pulsations  from 
the  subjacent  artery.  According  to  one  observer, 
the  walls  of  this  vein  are  often  as  thick  as  those 
of  the  popliteal  vein.  The  ulnar,  radial,  and 
median  veins  seldom  yield  enough  blood  on  vene- 
section, since  they  are  below  the  point  of  junction 
of  the  deep  median  vein,  and  thus  do  not  receive 
blood  from  the  deep  veins  of  the  limb.  The 
brachial  artery  has,  as  may  be  supposed,  been 
frequently  injured  in  bleeding;  and  at  the  period 
when  venesection  was  very  commonly  practised, 
arterio-venous  aneurysms  at  the  bend  of  the  elbow 
were  not  infrequent.  Since  the  principal  super- 
ficial lymphatic  vessels  run  with  these  veins,  and 
since  some  of  them  can  scarcely  escape  injury  in 
phlebotomy,  it  follows  that  an  acute  lymphan- 
gitis is  not  uncommon  after  the  operation,  especi- 
ally when,  the  point  of  the  lancet  being  unclean, 
septic  matter  is  introduced  into  the  wound. 

The  internal  cutaneous  nerve,  which  usually 
runs  in  front  of  the  median  basilic  vein,  may  be 
wounded  in  bleeding  from  that  vessel.  The  in- 
jury to  the  nerve,  according  to  Tillaux,  may  lead 
to  "  traumatic  neuralgia  of  extreme  intensity, 
and  very  chronic."  A  "  bent  arm  "  may  follow 
after  venesection,  and  Mr.  Hilton  believes  this 
to  be  often  due  to  injury  to  the  filaments  of  the 
musculocutaneous  nerve,  especially  to  the  inclu- 
sion of  those  filaments  in  a  scar  left  by  the  opera- 
tion. The  cutaneous  branches  of  this  nerve  lie 
over  the  median  cephalic  vein.  These  peripheral 
fibres  being  irritated,  the  muscles  supplied  from 
the  same  segment  of  the  cord  (biceps  and 
brachialis  anticus)  are  caused  to  contract  by  re- 
flex action.  Hence  the  bent  arm.  In  one  case  he 
cured  a  bent  arm  following  bleeding  by  resecting 
the    old    scar,    which    on    removal    was    found    to 


278  THE    UPPER    EXTREMITY  [Chap. 

have  included  within  its  substance  some  nerve 
filaments. 

There  is  a  lymphatic  gland  situated  over  the 
internal  intermuscular  septum  of  the  arm,  and 
just  above  the  internal  condyle.  It  receives  some 
of  the  surface  lymphatics  from  the  inner  side  of 
the  forearm,  and  two  or  three  inner  fingers.  In 
position,  it  is  the  lowest  of  the  constant  glands  in 
the  upper  limb.  In  the  same  position  occurs  an 
occasional  bony  outgrowth  of  the  inner  aspect  of 
the  humerus — the  supracondyloid  process.  The 
brachial  artery,  and  also  the  median  nerve,  may 
pass  beneath  and  internally  to  this  process. 

Brachial  artery.— In  forcible  flexion  of  the 
limb  the  artery  is  compressed  between  the  mus- 
cular masses  in  front  of  the  joint,  and  the  radial 
pulse  is  much  diminished  or  even  checked.  The 
artery  may  divide  in  the  lower  third  of  the  arm, 
and  in  such  cases  the  ulnar  artery  may  pass 
over  the  bicipital  fascia.  Aneurysms  at  the  bend 
of  the  elbow  have  been  treated  by  flexion  of  the 
limb,  that  position  bringing  more  or  less  direct 
pressure  to  bear  upon  the  sac.  In  full  extension 
of  the  joint  the  artery  becomes  flattened  out,  and 
the  radial  pulse  diminished.  In  the  over-ex- 
tension possible  with  fractured  olecranon  the 
pulse  may  be  stopped  at  the  wrist.  Forcible  ex- 
tension of  an  elbow  that  has  become  rigid  in  the 
bent  position  has  caused  rupture  of  the  brachial 
artery. 

The  ulnar  nerve  is,  from  its  position  at  the 
elbow,  very  liable  to  be  injured.  It  passes  in 
a  groove  behind  the  internal  condyle,  and  is 
crossed  by  a  bridge  of  fibrous  tissue  which  pre- 
vents its  displacement.  The  nerve  may  pass  in 
front  of  the  internal  condyle,  and  an  instance 
is  reported  where  the  nerve  slipped  forward  over 
that  eminence  whenever  the  elbow  was  bent 
(Quain).  In  exposing  the  ulnar  nerve  (for  nerve- 
stretching,  etc.)  behind  the  elbow  the  nerve  may 
be  found  quite  covered  by  an  occasional  muscle, 
the  epitrochleo-anconeus. 


XIII]  THE    ELBOW-JOINT  279 

The  elbow-join t.— The  strength  9f  this  joint 
depends  not  so  much  upon  either  ligaments  or 
muscles  as  upon  the  coaptation  of  the  bony  sur- 
faces. The  relations  of  the  olecranon  and  coronoid 
processes  to  the  humerus  are  such  that  in  certain 
positions  the  strength  of  the  joint  is  very  con- 
siderable. 

The  elbow,  being  a  pure  hinge-joint,  permits 
only  of  flexion  and  extension.  These  movements 
are  oblique,  so  that  in  flexion  the  forearm  in- 
clines inwards,  carrying  the  hand  towards  the 
middle  third  of  the  clavicle.  If  it  were  not  for 
the  obliquity  of  the  joint  line  it  would  be  possible 
for  the  hand  to  be  placed  flat  upon  the  shoulder 
of  the  same  side,  but  this  movement  is  only  pos- 
sible after  some  excisions  of  the  joint,  for  in  this 
operation  the  oblique  direction  of  the  articular 
surfaces  is  not  reproduced.  In  extreme  extension 
the  ulna  is  nearly  in  a  straight  line  with  the 
humerus  as  regards  their  lateral  planes,  while 
in  extreme  flexion  the  two  bones  form  an  angle 
of  from  30°  to  40°. 

Bursae.  —  Of  the  bur  see  about  the  joint  the 
large  subcutaneous  bursa  over  the  olecranon  is 
very  commonly  found  enlarged  and  inflamed 
(Fig.  57)  ;  and  when  inflamed  may  lead  to  exten- 
sive mischief  in  the  limb.  Its  enlargement  is 
favoured  by  certain  employments  involving  pres- 
sure on  the  elbow ;  thus,  the  disease  known  as 
11  miner's  elbow  "  is  merely  an  enlargement  of  this 
sac.  There  is  a  bursa  between  the  biceps  tendon 
at  its  insertion  and  the  bone,  the  relations  of  which 
to  the  nerves  of  the  forearm  are  worth  noting. 
A  case,  for  instance,  is  reported  where  this  bursa 
became  chronically  enlarged,  and  by  pressing 
upon  the  median  and  posterior  interosseous 
nerves  produced  loss  of  power  in  the  forearm 
(Agnew).  There  is  a  small  bursa  at  the  insertion 
of  the  triceps  (Fig.  57). 

Of  the  ligaments  of  the  elbow- joint,  the  an- 
terior and  posterior  are  comparatively  thin,  and 
the  latter  especially  soon  yields  to  the  pressure  of 


280 


THE    UPPER    EXTREMITY 


[Chap. 


fluid  within  the  joint  in  disease  of  the  articula- 
tion (Fig.  57).  The  internal  lateral  is  the  strong- 
est and  most  extensive  of  the  ligaments  of  the 
part.  From  its  rigidity,  its  extended  attachment, 
and  the  fact  that  it  serves  to  limit  not  only 
flexion  and  extension,  but  also  any  attempt  to 
wrench   the   forearm   laterally   from  the   arm,    it 


Triceps 


Olecramo/s 


/Iumerus 

Biceps 
Bracaiialis  Armcus 


Capsule 

Sup.  Loaicus. 
Epiphysis  of  Trochlea 
Coroaioid 
Bursa 


Biceps 
i/1ter055eus  art. 


Fig.  57. — Vertical  section  of  the  elbow-joint. 

The  epiphyseal  lines  of  the  olecranon  and  trochlea  are  shown  in  red. 
The  joint  is  semi-extended. 

A,  Usual  cap-like  epiphysis  of  olecranon  receiving  insertion  of  tri- 
ceps ;  B,  occasional  epiphysis  forming  the  upper  third  of  the 
olecranon.  Three  bursae  are  shown— over  the  olecranon,  under 
the  insertion  of  the  triceps,  and  at  the  insertion  of  the  biceps. 

happens  that  it  is  the  ligament  that  suffers  the 
most  often  in  M  sprains  "  of  the  elbow.  As  this 
ligament  is  attached  to  the  whole  length  of  the 
inner  border  of  the  olecranon,  it  may  assist  in 
preventing  separation  of  the  fragments  when  that 
process  has  been  fractured. 

Joint -disease. — In  disease  of  this  joint  the 
effusion    first  shows   itself   by   a   swelling   around 


XIII]  DISEASE    OF    THE    ELBOW-JOINT  281 

the  margins  of  the  olecranon.  This  is  explained 
by  the  facts  that  the  synovial  cavity  is  here 
nearest  to  the  surface,  and  that  the  posterior 
ligament  is  lax  and  thin  (Fig.  57).  Some 
swelling  is  also  soon  noticed  about  the  line  of 
the  radio-humeral  joint,  and  fluctuation  in  this 
situation  serves  to  distinguish  joint  effusion 
from  simple  enlargement  of  the  bursa  beneath 
the  triceps  tendon.  Deep-seated  swelling  may  be 
noted  about  the  front  of  the  joint  beneath  the 
brachialis  anticus,  owing  to  the  thinness  of  the 
anterior  ligament;  and  lastly,  about  the  external 
condyle.  The  density  of  the  internal  ligament 
prevents  bulging  of  the  synovial  membrane  on 
the  inner  side.  When  the  joint  suppurates  the 
pus  will  most  easily  reach  the  surface  by  travel- 
ling upwards  and  backwards  between  the  humerus 
and  the  triceps,  and  the  abscess  points,  therefore, 
very  commonly  at  one  or  other  border  of  that 
muscle.  The  pus  may  escape  beneath  the  brachi- 
alis anticus  in  front,  and  discharge  itself  near  the 
insertion  of  the  muscle.  The  diseased  elbow  tends 
to  assume  the  posture  of  semiflexion,  and  it  is 
interesting  to  observe  that  that  is  the  position 
assumed  by  the  joint  when  forcible  injections 
are  made  into  its  cavity  (Braune).  The  joint,  in 
fact,  holds  the  greatest  amount  of  fluid  when  it 
is  semiflexed.  As  regards  muscular  rigidity  of 
the  elbow,  due  to  reflex  irritation  from  disease, 
it  is  well  to  note  that  all  the  nerves  of  the  articu- 
lation, notably  the  musculo-spiral  and  musculo- 
cutaneous, supply  muscles  acting  upon  the  joint. 
The  relation  of  the  ulnar  nerve  to  the  joint  serves 
to  explain  cases  where  severe  pain  has  been  felt 
along  the  forearm  and  in  the  fingers,  in  parts 
corresponding  to  the  distribution  of  that  nerve. 
The  upper  epiphysis  of  the  radius  and  the  greater 
part  of  the  lower  epiphysis  of  the  humerus  are 
intrasynovial,  i.e.  come  within  the  capsule  of  the 
joint  (Fig.  58).  The  comparatively  small  upper 
epiphysis  of  the  ulna  is  only  partly  within  the 
capsule  (Fig.  57). 


282  THE    UPPER    EXTREMITY  [Chap. 

Dislocations  of  the  elbow. — These  are  many, 
and  may  be  thus  arranged.  (1)  Dislocations  of 
both  radius  and  ulna  either  backwards,  outwards, 
inwards,  or  forwards  (in  order  of  frequency). 
(2)  Dislocations  of  the  radius  alone  either  for- 
wards, backwards,  or  outwards  (in  order  of  fre- 
quency). (3)  Luxation  of  the  ulna  alone  back- 
wards. 

As  a  preliminary  it  may  be  convenient  to  note 
some  general  anatomical  considerations  in  con- 
nexion with  these  various  displacements. 

(a)  Antero-posterior  luxations  are  much  more 
common  than  lateral  luxations. — Displacements  in 
the  antero-posterior  direction  are  more  common 
because  the  movements  of  the  joint  take  place 
in  that  direction,  and  the  width  of  the  articular 
surface  of  the  humerus  from  before  backwards 
is  comparatively  small.  On  the  other  hand, 
there  is  normally  no  lateral  movement  of  the 
ejbow,  and  the  width  of  the  articulation  from 
side  to  side  is  considerable.  The  antero-posterior 
ligaments  are  feeble,  while  the  lateral  ligaments 
are  strong,  and  the  joint,  moreover,  receives  more 
muscular  support  at  its  sides  than  it  does  either 
behind  or  in  front.  The  mutual  support  afforded 
by  the  bones  to  one  another  is  weakened  in  the 
antero-posterior  direction  during  certain  move- 
ments. Thus  in  full  flexion  the  olecranon  has  but 
a  feeble  hold  upon  the  humerus,  while  in  exten- 
sion the  hold  of  the  coronoid  process  upon  that 
bone  is  even  less.  In  a  lateral  direction,  how- 
ever, movement  has  but  a  very  slight  effect  upon 
the  support  the  bones  mutually  derive  from  one 
another. 

(b)  Both  bones  of  the  forearm-  are  m,ore  often 
luxated  together  than  js  either  the  radius  alone 
or  the  ulna  alone. — This  depends  upon  the  power- 
ful ligamentous  connexion  between  the  radius 
and  ulna  on  the  one  hand,  and  the  absence  of 
such  connexion  between  the  humerus  and  the 
radius  on  the  other.  In  the  dead  subject  it  is  not 
difficult  to   dislocate  the  two  bones  of  the   fore- 


XIII]         DISLOCATIONS    OF    THE    ELBOW  283 

arm,  but  it  is  extremely  difficult  to  separate  the 
radius  from  the  ulna  without  great  breaking  and 
tearing  of  parts. 

(c)  The  commonest  dislocation  of  the  two  bones 
together  is  backwards,  the  rarest  is  forwards. — 
In  the  former  instance  the  movement  is  resisted  by 
the  small  coronoid  process,  in  the  latter  by  the 
large  and  curved  olecranon.  For  like  reasons  the 
luxation  outwards  is  less  rare  than  is  the  dis- 
placement inwards,  since  the  articular  surface  of 
the  humerus  inclines  downwards  and  inwards  on 
the  inner  side,  and  thus  affords  a  greater  obstacle 
in  that  quarter. 

(d)  If  a  single  bone  be  dislocated  it  will 
usually  be  the  radius. — This  follows  from  the 
absence  of  reliable  union  between  that  bone  and 
the  humerus,  from  the  greater  exposure  of  the 
radius  ("  the  handle  of  the  hand  ,;)  to  indirect 
violence,  and  from  its  greater  mobility.  The 
luxation  is  usually  forwards,  due  to  the  fact  that 
the  forms  of  violence  that  tend  most  often  to  dis- 
place the  bone  tend  also  to  draw  it  forwards. 
Paulet  asserts  that  the  posterior  part  of  the  ' 
orbicular  ligament  is  "much  more  resistant  "  than 
is  the  anterior  part.  The  luxation  of  the  ulna 
alone  occurs  in  the  backward  direction,  for  rea- 
sons that  will  be  obvious. 

Dislocations  of  all  kinds  may  be  partial  or 
complete.  More  usually  they  are  complete  when 
in  the  antero-posterior  direction,  and  partial 
when  the  luxation  is  lateral. 

Some  more  detailed  notice  may  now  be  taken 
of  the  only  two  forms  of  dislocation  at  the  elbow 
that  are  at  all  common. 

1.  Displacement  of  both  bones  backwards. — This 
may  be  effected  during  forced  extension.  Here 
the  point  of  the  olecranon  pressed  against  the 
humerus  acts  as  the  fulcrum  of  a  lever  of  l:he 
second  kind,  with  the  result  that  the  sigmoid 
cavity  is  forced  away  from  the  trochlea.  The 
addition  of  violence  to  the  forearm  in  a  back- 
ward or  upward  direction  would  effect  the  actual 


284  THE    UPPER    EXTREMITY  [Chap. 

displacement.  This  condition  may  be  illustrated 
by  a  fall,  when  running,  upon  the  fully  ex- 
tended hand.  The  lesion  may  also  be  produced 
by  certain  violent  wrenchings  of  the  limb.^  Mal- 
gaigne  maintained  that  the  particular  kind  of 
wrench  most  effectual  in  producing  luxation  was 
a  twisting  inwards  of  the  forearm  while  the 
elbow  was  semiflexed.  In  this  way  the  internal 
lateral  ligament  was  ruptured,  and  the  coronoid 
process  twisted  inwards  and  downwards  under 
the  humerus,  and  the  bones  thus  displaced  back. 
This  lesion  would  be  difficult  to  effect  while  the 
joint  was  fully  flexed.  In  the  complete  form  the 
coronoid  process  is  opposite  to  the  olecranon 
fossa.  It  can  hardly  occupy  that  hollow  (as  some- 
times described),  since  the  connexion  of  the  ulna 
to  the  radius,  and  the  projection  of  the  latter 
bone  behind  the  outer  condyle,  would  prevent  it 
from  actually  falling  into  the  fossa.  The  an- 
terior and  the  two  lateral  ligaments  are  usually 
more  or  less  entirely  torn,  while  the  posterior 
and  the  orbicular  ligaments  escape.  The  biceps  is 
drawn  over  the  lower  end  of  the  humerus,  and  is 
rendered  moderately  tense.  The  brachialis  anti- 
cus  is  much  stretched  and  often  torn.  The  an- 
coneus is  made  very  tense.  Both  the  median  and 
ulnar  nerves  may  be  severely  stretched. 

2.  Dislocation  of  the  radius  forwards. — This  may 
be  due  to  direct  violence  to  the  bone  from  behind, 
or  to  extreme  pronation,  or  to  falls  upon  the 
extended  and  pronated  hand.  The  anterior,  ex- 
ternal and  orbicular  ligaments  are  torn.  There 
would  seem  to  be  a  lack  of  evidence  in  support 
of  Hamilton's  statement  that  "  sometimes  the 
anterior  and  external  lateral  are  alone  broken, 
the  orbicular  ligament  being  then  sufficiently 
stretched  to  allow  of  the  complete  dislocation." 
The  biceps  being  relaxed,  the  pronators  act,  and 
the  limb  is  either  pronated  or  assumes  a  position 
midway  between  pronation  and  supination.  Some 
stretching  of  the  supinator  brevis  would  probably 
modify  the  amount  of  pronation.     A  difficulty  in 


XIII]  SPRAIN    OF    THE    ELBOW  285 

the  reduction  is  often  due  to  the  torn  annular 
ligament  coming  between  the  head  of  the  radius 
and  the  humeral  condyle. 

Sprain  of  the  elbow.— Mr.  J.  Hutchinson 
has  shown  that  in  young  children,  under  5  years, 
forcible  traction  of  the  limb  in  the  supinated 
position  may  cause  the  radius  to  slip  down- 
wards, away  from  the  orbicular  ligament,  which 
is  displaced  upwards.  In  such  cases  traction 
is  applied  before  the  muscles  of  the  elbow  have 
had  time  to  undergo  their  usual  reflex  con- 
traction, so  that  when  the  child  is  lifted  by  the 
hand  all  the  weight  falls  upon  the  ligaments  at 
the  elbow  instead  of  on  the  muscles.  #  The  only 
ligaments  which  resist  such  a  dislocation  are  (1) 
the  oblique  ulno-radial  ligament,  (2)  the  lower 
fibres  of  the  orbicular  ligament  which  grip  the 
head.  Flexion  of  the  elbow  in  the  pronated  posi- 
tion restores  the  ligament  to  its  normal  position. 
It  is  clear  that  this  displacement  is  the  anatomical 
basis  of  the  common  sprain  of  the  elbow  met  with 
in  young  children,  and  usually  due  to  violent 
traction  of  the  hand. 

Fractures  of  the  lower  end  of  the  humerus 
— These  are  :  (1)  A  fracture  just  above  the  con- 
dyles; (2)  the  "  T-shaped  fracture  "  involving  the 
joint;  (3)  fractures  of  the  internal,  and  (4)  of 
the  external  condyle;  (5)  fracture  of  the  internal 
epicondyle ;  and  (6)  separation  of  the  lower  epi- 
physis. All  these  fractures  are  more  common  in 
the  young. 

1.  The  fracture  "at  the  base  of  the  condyles," 
as  it  is  sometimes  called,  is  usually  situate  a  little 
above  the  olecranon  fossa,  where  the  humeral 
shaft  begins  to  expand.  It  is  commonly  trans- 
verse from  side  to  side,  and  oblique  from  behind 
downwards  and  forwards.  It  is  generally  the  re- 
sult of  a  blow  inflicted  upon  the  extremity  of  the 
elbow.  Probably  the  tip  of  the  olecranon  driven 
sharply  against  the  bone  acts  like  the  point  of 
a  wedge,  and  takes  an  important  share  in  the 
production  of  the  fracture.     The  lower  fragment, 


286  THE    UPPER    EXTREMITY  [Chap. 

together  with  the  bones  of  the  forearm,  is  gener- 
ally carried  backwards  by  the  triceps,  and  up- 
wards by  that  muscle,  the  biceps,  and  the  brachi- 
als anticus.  The  median  or  ulnar  nerves,  especi- 
ally the  latter,  may  be  severely  damaged. 

2.  The  "T=shaped  fracture"  is  but  a  variety 
of  the  lesion  just  noted.  In  addition  to  the  trans- 
verse fracture  above  the  condyles,  there  is  also  a 
vertical  fracture  running  between  the  two  con- 
dyles into  the  joint.  The  lower  fragment  is  thus 
divided  into  two  parts.  The  displacement  is  the 
same.  The  fracture  is  usually  due  to  a  fall  upon 
the  bent  elbow,  and  here  possibly  the  tip  of  the 
olecranon  again  acts  as  a  wedge,  producing  the 
transverse  fracture,  while  the  prominent  ridge 
along  the  middle  of  the  greater  sigmoid  cavity, 
acting  as  a  second  wedge,  produces  the  vertical 
fracture  into  the  joint. 

3,  4,  and  5.  For  surgical  purposes  it  is  well 
to  limit  the  term  "  condyle  "  to  such  parts  of  the 
extremity  of  the  humerus  as  are  within  the  cap- 
sule, and  the  term  "  epicondyle  "  to  such  parts 
of  the  lower  projections  of  the  bone  as  are  with- 
out the  joint. 

In  the  so-called  fracture  of  the  inner  condyle 
the  line  of  separation  generally  commences  about 
half  an  inch  above  the  tip  of  the  epicondyle 
(and,  therefore,  outside  the  joint),  and,  running 
obliquely  outwards  through  the  olecranon  and 
coronoid  fossae,  enters  the  articulation  through 
the  centre  of  the  trochlear  surface  (Hamilton). 
The  fragment  is  often  displaced  a  little  upwards, 
backwards,  and  inwards,  the  ulna  going  with  it. 

In  the  fracture  of  the  external  condyle  the  line 
commences  also  above  the  epicondyle  and  outside 
the  joint,  and,  running  downwards,  enters  the 
joint  usually  between  the  trochlear  surface  and 
the  surface  for  the  radius.  The  displacement  is 
trifling  and  inconstant. 

On  account  of  its  insignificant  size,  a  fracture 
of  the  external  epicondyle  is  scarcely  possible. 
Fractures  of  the   inner   epicondyle  are,   however, 


XIII1         FEACTUKES    OF    THE    HUMERUS 


287 


quite  common,  the  joint  remaining  free  (Fig.  58). 
This  epicondyle  exists  as  a  distinct  epiphysis, 
which  unites  at  the  age  of  eighteen,  and  which  at 
any  time  before  that  age  may  be  separated  from 
the  bone  by  direct  injury  or  muscular  violence. 
Owing  to  the  dense  aponeurotic  fibres  that  cover 
the  part,  much  displacement  of  the  fragment  is 
uncommon.  When  displacement  exists,  it  is  in 
the  general  line  of  the  common  flexor  muscles  that 
arise  from  the  tip  of  the  process.  In  such  cases 
the  ulnar  nerve,  which  lies  behind  the  process,  is 
often   damaged. 

6.  The  lower  epiphysis  (Fig.  58).— In  the  car- 
tilaginous lower  extrem- 
ity of  the  humerus,  four 
ossific  centres  appear, 
one  for  each  of  the  fol- 
lowing parts  :  capitel- 
lum,  trochlea,  external 
and  internal  epicon- 
dyles.  The  three  centres 
named  first  unite  to  form 
the  main  epiphysis,  that 
for  the  internal  epicon- 
dyle remaining  separate 
(Fig.  t  bS\  The  epiphy- 
seal line  is  thus  divided 
into  two  parts,  and  is 
irregular  in  form ;  it  lies 
both  within  and  without 
the  capsule  of  the  joint 
(Fig.  58);  Its  position 
may  be  indicated  by  a 
line  drawn  from  the 
upper  border  of  the  ex- 
ternal to  the  lower  border 
of  the  internal  epicon- 
dyle. The  lower  epiphy- 
sis joins  the  shaft  at 
the  age  of  seventeen.  Thus,  after  seventeen  the 
growth  of  the  bone  must  depend  upon  the  activity 
of  the  upper  epiphysis,  which  does  not  unite  until 


Fig.  58. — Lower  epiphysis  of 
the  humerus  from  behind. 

A,  Centre  for  internal  epicon- 
dyle ;  B,  c,  D,  united  centres 
or  the  trochlea,  capitellum , 
and  external  epicondyle  ;  E, 
E,  epiphyseal  line  ;  the  cap- 
sular attachment  is  indicated 
by  red  lines. 


^88  THE    UPPER    EXTREMITY  [Chap. 

twenty.  Excision  of  the  elbow,  therefore,  after 
the  sixteenth  or  seventeenth  year,  will  not  be  fol- 
lowed by  arrest  of  development  in  the  limb,  even 
if  the  epiphyseal  line  has  been  transgressed  by 
the  saw.  Several  cases  are,  however,  reported  of 
marked  arrest  of  growth  in  the  limb  following 
upon  injuries  to  the  lower  epiphysis  before  the 
sixteenth  year,  and  to  the  upper  epiphysis  before 
twenty.  Since  the  greater  part  of  the  epiphyseal 
line  is  within  the  capsule,  it  follows  that  but 
little  displacement,  other  than  a  slight  movement 
backwards,  is  consequent  upon  the  separation  of 
the  mass. 

Fractures  of  the  olecranon  are  commonly 
due  to  direct  violence,  and  in  a  few  cases  to  severe 
indirect  violence  applied  to  the  lower  end  of  the 
humerus  or  upper  end  of  the  ulna.  Instances  of 
fracture  by  muscular  action  are  few,  and  open 
to  some  question.  The  fracture  is  most  commonly 
met  with  about  the  middle  of  the  process,  just 
where  it  begins  to  be  constricted,  and  is  usually 
transverse  in  direction.  The  amount  of  displace- 
ment effected  by  the  triceps  varies,  and  depends 
upon  the  extent  to  which  the  dense  periosteum 
about  the  process  and  the  ligaments  that  are 
attached  to  it  are  torn.  The  olecranon  is  de- 
veloped mainly  from  the  shaft  of  the  ulna  (Fig. 
57).  There  is  a  scale-like  epiphysis,  however,  at 
the  summit  of  the  process  which  joins  the  rest  of 
the  olecranon  at  the  age  of  seventeen.  Occasion- 
ally another  epiphyseal  centre  occurs,  giving 
origin  to  the  upper  third  of  the  olecranon  (Fig. 
57).  In  young  subjects  the  scale-like  epiphysis 
may  be  separated  by  violence,  or  the  cartilagin- 
ous olecranon  may  be  dissevered  from  the  rest  of 
the  bone.  The  common  fracture  of  the  adult 
olecranon  does  not  follow  the  epiphyseal  line. 

Fracture  of  the  coronoid  process  is  an 
extremely  rare  accident,  sometimes  occurring  in 
dislocation  backwards  of  the  ulna.  It  is  impos 
sible  to  understand  how  the  process  can  be  torn 
off  by  the  action  of  the  brachialis  anticus,  as  some 


XIII]  EESECTION    OF    THE    ELBOW  289 

maintain,  since  that  muscle  is  inserted  rather 
into  the  ulna  at  the  base  of  the  projection  than 
into  the  process  itself  (Fig.  57).  Nor  can  it  be 
separated  as  an  epiphysis,  as  supposed  by  others, 
since  it  does  not  exist  as  such. 

Fractures  of  the  head  or  neck  ot  the  radius 
are  rare,  and  occur  usually  with  dislocation  or 
other  severe  injury.  The  head  is  commonly  found 
split  or  starred,  and  the  lesion,  if  limited  to  the 
head,  could  hardly  be  diagnosed.  The  upper 
epiphysis  of  the  radius  is  entirely  within  the 
limits  of  the  annular  ligament,  and  could  scarcely 
be  separated  in  a  simple  lesion.  It  is  a  mere  disc 
of  cartilage  joining  the  shaft  at  the  age  of  seven- 
teen. When  the  neck  is  broken  the  upper  end  of 
the  lower  fragment  is  drawn  well  forwards  by 
the  biceps  muscle. 

Resection  of  the  elbow  may  be  performed  in 
many  ways.  In  all  procedures  there  is  danger  of 
injuring  the  ulnar  nerve,  and  some  little  difficulty 
often  in  clearing  the  prominent  internal  condyle. 
If  the  knife  be  kept  close  to  the  bone,  no  vessel  of 
any  magnitude  should  be  divided.  The  muscles 
most  disturbed  are  the  triceps,  anconeus,  supin- 
ator brevis,  extensor  carpi  ulnaris,  extensor  carpi 
radialis  brevior,  and  brachialis  anticus.  It  is 
most  important  to  preserve  the  periosteum  over 
the  olecranon  and  the  external  lateral  expansion 
of  the  triceps  tendon  to  the  deep  fascia  of  the 
forearm,  so  that  this  muscle  may  still  act  as 
an  extensor.  It  is  never  necessary  to  divide 
the  insertion  of  the  brachialis  anticus,  still  less 
of  the  biceps,  although  some  few  fibres  of  the 
former  muscle  may  be  separated  in  removing 
the  upper  surface  of  the  ulna.  By  the  sub- 
periosteal method  the  periosteum  is  carefully 
peeled  off  from  all  the  parts  to  be  resected,  and 
is  preserved.  By  this  means  the  triceps  retains 
a  hold  upon  the  ulna,  and  the  restoration  of 
the  joint  is  more  complete.  The  functions  of 
the  joint  may  be  well  restored  after  resection, 
especially   when   performed   by   the   subperiosteal 


290  THE    UPPER    EXTREMITY       [Chap.  XIII 

method ;  but  it  would  appear  that  after  no  method 
are  the  anatomical  details  of  the  joint  repro- 
duced. Thus,  in  a  successful  case,  the  new  joint 
will  assume  the  bimalleolar  form,  and  will  re- 
semble the  ankle-  rather  than  the  elbow-joint.  The 
humerus  throws  out  two  malleoli  on  the  sites  of 
the  normal  condyles,  and  in  the  concavity  between 
them  the  ulna  and  radius  are  received.  Between 
the  ulna  and  the  humerus  new  ligaments  form, 
and  a  new  annular  ligament  for  the  radius  is  also 
developed. 

Position  of  the  main  nerves  at  the  elbow. 
— The  musculo-spiral  is  found  in  front  of  the 
external  epicondyle,  under  cover  of  the  supinator 
longus,  where  it  divides  into  posterior  interos- 
seus  and  radial.  The  median  is  situated  at  the 
inner  border  of  the  brachial  artery;  the  ulnar  lies 
in  a  groove  behind  the  internal  epicondyle. 


CHAPTER    XIV 

THE      FOREARM 

Surface  anatomy.  —  At  its  upper  half,  and 
especially  in  its  upper  third,  the  limb  is  much 
wider  in  its  transverse  than  in  its  anteroposterior 
diameter.  A  horizontal  section  through  this  part 
will  show  a  cut  surface  that  is  somewhat  oval 
in  outline,  and  is  at  the  same  time  flattened  in 
front  and  more  convex  behind.  This  outline  is 
best  seen  in  muscular  subjects,  and  depends  chiefly 
upon  the  development  of  the  lateral  masses  of 
muscle  that  descend  from  the  condyles.  In  the 
non-muscular,  the  limb,  even  in  its  highest  parts, 
tends  to  assume  a  rounded  rather  than  an  oval 
outline.  In  women  and  children,  also,  the  limb 
is  round,  owing  to  the  comparatively  slight  de- 
velopment of  the  lateral  muscular  masses,  and  to 
the  accumulation  of  fat  on  the  front  and  back  of 
the  limb.  The  posterior  surface  of  the  forearm 
in  a  vigorous  subject  presents  along  its  outer 
border  a  prominence  formed  by  the  supinator 
longus  and  the  two  radial  extensors,  which  become 
tendinous  below  the  centre  of  that  border.  On 
the  lower  third  of  this  edge  is  a  slight  eminence, 
directed  obliquely  downwards,  outwards,  and  for- 
wards, and  due  to  the  crossing  of  the  extensors 
of  the  thumb.  In  the  middle  of  the  posterior 
surface  is  another  elevation,  running  down  from 
the  outer  condyle,  and  formed  mainly  by  the 
extensor  communis.  To  the  inner  side  of  this 
eminence  is  a  groove,  well  seen  in  the  very  mus- 
2t)l 


292  THE    UPPER    EXTREMITY  [Chap. 

cular,  that  indicates  the  posterior  border  of  the 
ulna.  The  ulna  is  subcutaneous  throughout  its 
entire  extent,  and  can  be  readily  examined.  The 
upper  half  of  the  radius  is  too  deeply  placed  to 
be  well  made  out,  but  the  lower  half  of  the  bone 
can  be  easily  felt  beneath  the  skin.  The  course  of 
the  radial  artery  is  represented  by  a  line  drawn 
from  the  outer  border  of  the  biceps  tendon  at  the 
bend  of  the  elbow  to  a  point  in  front  of  the  styloid 
process  of  the  radius.  The  pulse  is  felt  between 
the  styloid  process  and  tendon  of  the  flexor  carpi 
radialis  where  the  artery  rests  on  the  lower  ex- 
tremity of  the  radius.  The  middle  and  lower 
thirds  of  the  ulnar  artery  follow  a  line  from 
the  inner  condyle  to  the  radial  side  of  the  pisi- 
form bone.  The  upper  third  would  be  repre- 
sented by  a  line  drawn  from  the  middle  of  the 
bend  of  the  elbow  to  meet  the  first  line  at  the 
junction  of  the  upper  and  middle  thirds  of  the 
inner  border  of  the  forearm.  Such  a  line  would 
be  slightly  curved,  with  its  concavity  outwards. 
The  tendons,  etc.,  that  can  be  demonstrated  at  the 
lower  extremity  of  the  forearm  will  be  considered 
in  the  description  of  the  wrist. 

Vessels. —  It  is  well  to  note  the  very  free  anas- 
tomoses that  exist  along  the  greater  part  of  the 
limb  between  the  ulnar  and  radial  arteries.  This 
fact  was  illustrated  by  a  case  under  my  care 
in  the  London  Hospital.  A  seafaring  man 
had  inflicted  upon  his  left  forearm  three  deep 
transverse  wounds  across  the  front  of  the  limb 
with  a  sharp  knife.  The  wounds  were  about 
1\  inches  apart.  The  radial  artery  was  divided  in 
each  of  the  wounds,  and  that  vessel,  therefore, 
presented  six  cut  ends.  It  would  appear  to  be 
sufficient  to  ligature  the  proximal  and  distal  ends 
of  the  wounded  vessel,  and  to  leave  the  two  iso- 
lated portions  of  the  artery,  each  about  lj  inches 
in  length,  alone.  I  applied  ligatures  to  five  of 
the  divided  ends,  leaving  the  lower  end  of  thn 
upper  isolated  piece  of  the  artery  untied,  and 
watched  the  effect.     During  the  course  of  the  day, 


XIV  i  THE    FOREARM  293 

when  the  man  had  rallied  from  the  profound 
t'aintness  due  to  the  great  loss  of  blood  he  had 
experienced,  copious  bleeding  took  place  from  this 
single  unsecured  end  of  the  vessel,  and  it,  of 
course,  had  also  to  be  tied. 

There  is  a  singular  absence  of  large  blood- 
vessels or  nerves  along  the  posterior  aspect  of  the 
forearm,  and  it  is  significant  that  this  is  the 
aspect  of  the  limb  most  exposed  to  injury.  For  a 
hand's-breadth  below  the  olecranon  there  is  almost 
an  entire  absence  of  superficial  veins. 

The  median  nerve  passes  between  the  two 
heads  of  the  pronator  teres,  and  may  possibly  be 
compressed  by  that  muscle  when  in  vigorous 
action.  At  the  wrist  the  median  is  between  the 
tendons  of  the  flexor  carpi  radialis  and  flexor 
sublimis  digitorum;  it  lies  deep  to  the  tendon 
of  the  palmaris  longus,  which  serves  as  a  useful 
guide  to  its  position. 

Bones  ol  the  forearm. — Transverse  sections 
of  the  limb  at  various  levels  show  that  the 
radius  and  ulna  are  in  all  parts  nearer  to  the 
posterior  than  the  anterior  aspect  of  the  ex- 
tremity (Figs.  59  and  60).  This  relation  is  the 
more  marked  the  higher  up  the  section.  The  two 
bones  are  nearest  to  the  centre  of  the  limb  about 
the  lower  end  of  the  middle  third.  At  the  upper 
part  of  the  forearm  the  muscles  are  found  mainly 
at  the  sides  and  in  front.  The  lower  the  section 
proceeds  down  the  limb,  the  less  will  the  bones  be 
covered  at  the  sides,  and  the  more  equally  will 
the  soft  parts  be  found  distributed  about  the 
anterior  and  posterior  aspects  of  the  limb.  It 
will  be  noticed  that  where  one  bone  is  the  more 
substantial  the  other  is  the  more  slender,  as  near 
the  elbow  and  wrist;  and  that  it  is  about  the 
centre  of  the  limb  that  the  two  are  most  nearly  of 
equal  strength.  The  proximity  of  the  two  bones, 
and  especially  of  the  ulna,  to  the  posterior  aspect 
of  the  limb  permits  them  to  be  easily  examined 
from  that  surface,  while  it  is  from  the  same  aspect 
that    resections    and    other    operations    upon    the 


294 


THE    UPPER    EXTREMITY 


[Chap. 


bones  are  most  readily  performed.  It  will  be 
understood,  moreover,  that  in  compound  frac- 
tures, due  to  penetration  of  fragments,  the  wound 
is  more  usually  on  the  posterior  aspect  of  the 
limb. 

The    important   movements   of   pronation   and 
supination  take   place  between   these  bones,    and 

round      an       axis 
fy  2  corresponding     to 

a  line  drawn 
through  the  head 
of  the  radius,  the 
lower  end  of  the 
ulna,  and  the 
metacarpal  bone 
of  the  ring-finger. 
In  extreme  pro- 
nation the  radius 
crosses  the  ulna 
obliquely  ;  the  two 
bones  are  almost 
in  contact  at  the 
point  of  crossing  ; 
the  lower  fibres 
of  the  interosseus 
membrane  and  the 
posterior  radio- 
ulnar ligament 
are  tight.  "  The 
chief  influ- 
ence in  check- 
ing supination  is 
not  to  be  found 
in  ligament  at  all, 
but  in  the  contact 
of  the  posterior 
edge  of  the  sig- 
moid cavity  of  the 
radius  with  the  tendon  of  the  extensor  carpi 
ulnaris,  as  it  lies  in  the  groove  between  the  styloid 
process  and  the  round  head  of  the  ulna"  (Sir 
H.  Morris).     Of  the  two  movements,  supination  is 


section 
of    the 


Fig.      59.  —  Transverse 
through    the    middle 
forearm.     (Braune.) 

a,  Badius  ;  b,  ulna  :  c,  supinator  longus ; 
d,  flexor  longus  pollicis  :  e,  flexor 
carpi  radialis  :  /,  palmaris  longus  ; 
g,  flexor  sublimis  digitorum  ;  h, 
flexor  carpi  ulnaris ;  i,  flexor  pro- 
fundi s  digitorum  ;  fc,  extensor  carpi 
ulnaris  ;  Z,  extensor  indicis  :  w,  ex- 
tensor minimi  digiti  ;  n,  extensor 
communis  digitorum  ;  o,  extensor 
ossis  and  extensor  secundi  internodii 
pollicis  ;  q,  extensor  carpi  radialis 
brevior  ;  r,  extensor  carpi  radialis 
longior  ;  s,  pronator  radii  teres;  1, 
radial  vessels  and  nerve  ;  2,  ulnar 
vessels  and  nerve. 


XIV]  THE    FOREARM  295 

the  more  powerful.  This  is  illustrated  in  many 
ways.  In  using  a  screw-driver  or  a  gimlet 
the  movements  of  pronation  and  supination  are 
conspicuously  involved,  but  the  main  force  is 
applied  during  supination.  It  is  significant  that 
the  thread  of  a  corkscrew  is  so  turned  that  it 
shall  be  inserted  by  supination  rather  than  by 
pronation. 

The  only  position  in  which  the  two  bones  are 
parallel  to  one  another  is  the  mid-position  be- 
tween pronation  and  supination.  It  is  in  this 
posture  only  that  the  interosseous  membrane  is 
uncoiled  throughout.  Hence  the  selection  of  this 
position  in  the  adjustment  of  most  fractures  of 
the  forearm.  The  interosseous  space  is  an  ir- 
regular ellipse,  a  little  larger  below  than  above. 
It  is  narrowest  in  full  pronation,  widest  in 
supination,  and  nearly  as  wide  in  the  mid- 
position. 

It  may  be  noted  that  the  oblique  ligament 
tends  to  resist  forces  that  would  drag  the  radius 
away  from  the  humerus,  and  takes  the  place 
and  the  function  of  a  direct  ligament,  passing 
from  the  humerus  to  the  radius,  while  the 
interosseous  membrane,  from  the  obliquity  of 
its  fibres,  makes  the  ulna  take  a  share  in  the 
strain  put  upon  the  radius  when  that  bone  is 
forced  upwards,  as  in  resting  on,  or  pushing 
with,   the   palm. 

Fractures  of  llie  forearm. — The  two  bones 
are  more  often  broken  together  than  is  either  the 
radius  or  the  ulna  alone.  The  radius,  when 
broken  alone,  is  usually  fractured  by  indirect 
violence,  since  it^  receives  more  or  less  entirely 
all  shocks  transmitted  from  the  hand.  The  ulna, 
on  the  contrary,  is  more  often  broken  by  direct 
violence,  it  being  the  more  superficial  and  exposed 
of  the  two  bones.  For  example,  in  raising  the 
arm  to  ward  off  a  blow  from  the  head,  the  ulna 
becomes  uppermost.  When  the  two  bones  are 
broken  together,  the  violence  may  be  direct  or 
indirect.       Malgaigne  reports  a  case  where  both 


296  THE    UPPER    EXTREMITY  [Chap. 

holies  in  a  patient  were  broken  by  muscular  vio- 
lence when  he  was  shovelling  earth.  Here  the  bones 
probably  were  broken  between  the  two  opposed 
forces  represented  by  the  biceps  and  brachialis 
anticus  above  and  the  weight  of  the  loaded  shovel 
in  the  hand  below.  When  both  bones  are  broken 
and  the  fractures  are  oblique,  shortening  may  be 
produced  by  the  united  action  of  the  flexors  and 
extensors.  The  displacement  varies  greatly,  and 
depends  rather  upon  the  direction  of  the  violence 
than  upon  muscular  action.  Thus  Hamilton 
says  :  "  I  have  seen  the  fragments  deviate  slightly 
in  almost  every  direction. "  If  union  be  delayed, 
the  delay  is  usually  in  the  radius,  since  it  is  the 
more  mobile  of  the  bones. 

When  the  radius  alone  is  broken  (1)  between 
the  insertions  of  the  biceps  and  pronator  teres, 
the  upper  fragment  is  flexed  by  the  biceps  and 
fully  supinated  by  that  muscle  and  the  small 
supinator.  The  lower  fragment  will  be  pronated 
by  the  two  pronators,  and  drawn  in  towards 
the  ulna  by  means  of  these  muscles.  If  such 
a  fracture  be  put  up  with  the  hand  midway 
between  the  prone  and  supine  positions,  the 
following  evils  result  :  the  upper  fragment  is 
fully  supinated  by  the  muscles;  the  lower  frag- 
ment is  placed  in  the  mid-position  by  the  splints. 
It  follows  that  the  proper  axis  of  the  bone 
is  not  reproduced,  and  the  use  of  the  biceps 
and  supinator  brevis  as  supinators  is  entirely 
lost.  Thus  patients  so  treated  usually  recover 
with  great  loss  in  the  power  of  supination;  and 
to  avoid  this  ill  result,  it  is  advised  to  put  the 
limb  up  in  full  supination,  so  that  the  two  frag- 
ments may  unite  in  their  proper  axis,  the  upper 
fragment  being  supinated  by  the  muscles,  the 
lower  by  the  splints.  (2)  When  the  fracture  is 
between  the  insertions  of  the  two  pronators,  the 
upper  fragment  may  be  carried  a  little  forwards 
by  the  biceps  and  pronator  teres,  and  drawn  to- 
wards the  ulna  by  the  latter  muscle.  The  lower 
fragment    will    be    adducted   to   the    ulna   by    the 


XIV]  FRACTURES    OF    THE    FOREARM  297 

pronator  quadratus,  and  its  upper  end  will  be 
still  further  tilted  towards  that  bone  by  the 
action  of  the  supinator  longus  upon  the  styloid 
process. 

When  the  ulna  alone  is  broken,  as,  for  example, 
about  its  middle,  the  upper  fragment  may  be 
drawn  a  little  forwards  by  the  brachialis  anticus, 
while  the  lower  fragment  will  be  carried  towards 
the  radius  by  the  pronator  quadratus. 

The  displacement,  however,  in  all  cases  is  in- 
fluenced as  much  by  the  direction  of  the  violence 
as  by  the  action  of  muscles.  When  the  fragments, 
after  fracture  of  one  or  of  both  bones,  fall  in 
towards  one  another,  so  as  to  meet  across  the 
interosseous  space,  attempts  are  sometimes  made 
to  separate  the  broken  ends  and  to  preserve  the 
integrity  of  the  space  by  the  use  of  graduated 
pads.  These  pads,  however,  if  applied  with 
sufficient  force  to  separate  the  fragments,  will 
probably  compress  one  or  both  of  the  arteries  of 
the  limb,  and  cause  great  distress,  resulting  in  a 
peculiar  form  of  paralysis,  due,  it  is  believed, 
to  the  compression  shutting  off  the  blood-supply 
to  the  muscles.  Subsequently  the  muscles  undergo 
contracture. 

The  fact  that  the  bulk  of  the  venous  blood  of 
the  forearm  is  returned  by  surface  veins  may 
explain  the  ready  occurrence  of  severe  cedema  in 
the  limb  when  fractures  are  treated  with  im- 
properly applied  splints  or  bandages.  Since 
the  arteries  also  can  be  readily  affected  by 
pressure,  it  follows  that  gangrene,  as  a  result 
of  improper  treatment,  is  more  common  after 
fracture  of  the  forearm  than  after  fracture  in 
any  other  part. 

Amputation  of  the  forearm. — In  amputa- 
tion of  the  forearm  by  double  transfixion  flaps, 
at  about  the  upper  part  of  the  middle  third  the 
parts  would  be  cut  in  the  following  manner  (Fig. 
59)  :  On  the^  face  of  the  anterior  flap  would  be 
seen  from  without  inwards  the  supinator  longus 

(cut  the  whole  length  of  the  flap),  then  the  flexor 
K# 


298 


THE    UPPER    EXTREMITY 


[Chap. 


sublimis  (cut  to  a  like  extent),  and,  lastly,  the 
flexor  carpi  ulnaris.  Between  the  supinator 
longus  and  the  flexor  sublimis  the  divided  end 
of  the  pronator  teres  is  seen ;  and  between  the 
flexor  sublimis  and  the  skin  would  lie  the  flexor 

carpi  radialis  and  the 
palmaris  longus.  The 
latter  would  appear  as 
a  tendon  at  the  inner 
border  of  the  flap.  In 
the  angle  between  the 
two  flaps  would  be 
found,  in  front  of  the 
radius,  a  little  of  the 
flexor  longus  pollicis, 
and  in  front  of  the 
ulna,  the  flexor  profun- 
dus, the  latter  cut  much 
the  longer.  Quite  close 
to  the  radius,  and  for 
the  most  part  behind 
it,  would  be  the  lowest 
part  of  the  small  supin- 
ator, while  behind  the 
ulna  would  be  the  cut 
fibres  of  the  upper  end 
of  the  extensor  ossis. 
On  the  face  of  the 
posterior  flap  would 
be  seen  from  without 
inwards  the  extensor 
carpi  radialis  longior 
and  brevior,  the  ex- 
tensor communis,  the 
extensor    of    the    little 


]l   o 

Fig.  60. — Transverse  section 
through  the  lower  third 
of  the  forearm.  {Braune.) 

a,  Radius  ;  b,  ulna  ;  c,  supinator 
longus  ;  d,  flexor  longus  pol- 
licis ;  e,  flexor  carpi  radialis  ; 
/,  palmaris  longus  ;  f/,  flexor 
sublimis  digitorum  ;  h,  flexor 
carpi  ulnaris  ;  i,  flexor  pro- 
fundus digitorum  ;j,  pronato 
quadratus  ;  k.  extensor  carpi 
ulnaris  ;  I,  extensor  indicis  ; 
m,  extensor  minimi  digiti  ; 
n,  extensor  communis  digi- 
torum ;  o,  extensor  secundi 
internodii  pollicis  ;  p,  exten- 
sor primi  internodii  pollicis  : 
q,  extensor  carpi  radialis 
brevior ;  r,  extensor  carpi 
radialis  longior,  with,  in  front 
of  it,  the  extensor  ossis  meta- 
carpi  pollicis  ;  1,  radial 
vessels  ;  2,  ulnar  vessels  ;  3, 
median  nerve. 


finger,  and  the  extensor 
carpi  ulnaris.  The  radial  artery  will  run  the 
whole  length  of  the  anterior  flap,  and  be  cut 
near  its  outer  border  to  the  inner  side  of 
the  supinator  longus.  The  ulnar  artery  will  be 
cut  shorter,  in  front  of  the  bone,  and  between 
the   flexor    sublimis    and   flexor    profundus.      The 


XIV]        AMPUTATION    OF    THE    FOREABM 


299 


anterior  interosseous  vessels  will  be  divided  im- 
mediately in  front  of  the  interosseous  membrane. 
The  posterior  interosseous  vessels  will  be  cut  long, 
and  will  be  found  between  the  superficial  and 
deep  muscles. 

Fig.  60  shows  the  relation  of  the  parts  as 
they  would  be  cut  in  a  circular  amputation  of 
the  limb  through  the  lower  third. 


CHAPTER   XV 

THE  WRIST  AND  HAND 

Surface  anatomy. — The  following  structures 
can  be  made  out  about  the  wrist :  Commencing 
at  the  outer  side,  the  lower  extremity  and  styloid 
process  of  the  radius  can  be  well  defined.  The 
bone  is  here  superficial  in  front  and  behind.  The 
styloid  process  lies  more  anteriorly  than  does  the 
corresponding  process  of  the  ulna,  and  also  de- 
scends about  |  an  inch  lower  down  the  limb. 
The  outer  surface  of  the  radius  at  the  wrist  is 
crossed  by  the  tendons  of  the  extensor  ossis  meta- 
carpi  and  extensor  brevis  pollicis.  These  are  very 
distinct  when  the  thumb  is  abducted,  and  the  slit- 
like interval  between  the  two  can  be  felt.  About 
the  centre  of  the  front  of  the  wrist  is  the  pal- 
maris  longus  tendon,  which  is  usually  the  most- 
conspicuous  of  the  tendons  on  this  aspect  of 
the  joint.  It  will  be  found  absent  in  quite  10  per 
cent,  of  wrists  examined.  It  is  rendered  most 
prominent  when  the  wrist  is  a  little  flexed,  the 
fingers  and  thumbs  extended,  and  the  thenar  and 
hypothenar  eminences  as  much  approximated  as 
possible.  A  little  to  its  outer  side  is  the  larger  but 
less  prominent  tendon  of  the  flexor  carpi  radialis. 
In  the  narrow  groove  between  these  two  tendons 
lies  the  median  nerve,  and  on  the  radial  side  of 
the   flexor   carpi    radialis    is   the   radial    artery. 

*  Sometimes  the  superficial  is  volae  arises  higher  and  is  larger  than 
usmal.  It  then  runs  by  the  tide  of  the  radial  in  front  of  the  wrist,  and, 
giving  additional  volume  to  the  pulse,  has  been  the  foundation  of  the 
go-called  "double  pulse." 

300 


Chap.  XV]     SURFACE    ANATOMY    OF    WRIST         301 

The  venae  comites  surround  the  artery,  and  when 
distended  alter  the  character  of  the  pulse  (Hill). 
Towards  the  inner  border  of  the  wrist  the  flexor 
carpi  ulnaris  tendon  is  evident,  descending  to 
the  pisiform  bone.  It  is  rendered  most  distinct 
when  the  wrist  is  slightly  flexed  and  the  little 
finger  pressed  forcibly  into  the  palm.  In  the 
hollow  which  this  posture  produces  between  the 
last-named  tendon  and  the  palmaris  longus  lie 
the  flexor  sublimis  tendons,  and  just  to  the  radial 
side  of  the  flexor  carpi  ulnaris  the  pulsations  of 
the  ulnar  artery  can  be  felt.  Beneath  the  thin 
skin  in  front  of  the  wrist  a  part  of  the  plexus  of 
veins  can  be  seen  that  end  in  the  median  and 
anterior  ulnar  trunks.  The  ulnar  nerve  grooves 
the  radial  side  of  the  pisiform  bone. 

At  the  back  of  the  wrist  the  following  tendons 

can  be  readily  distinguished  from  without  inwards 

(Fig.   62)  :   the  extensor  longus  pollicis  (extensor 

secundi  internodii),  the  extensor  communis,  and 

the   extensor   carpi   ulnaris.      Of   these,    the   most 

prominent   is    the    first-named.        It    is    rendered 

!    most  distinct  when  the  thumb  is  forcibly  abducted 

!    and  extended.     The  tendon   leads  up   to  a  small 

!    but    prominent    bony    elevation    on    the    back    of 

i    the   radius   that  marks   the   outer   border   of   the 

J    osseous    groove    for    its    reception.     This    tendon, 

j    when  it  reaches  the  radius,   points  to  the  centre 

!    of  the   posterior   surface   of  that  bone,    and   also 

1    indicates    roughly    the    position    of    the    interval 

between  the  scaphoid  and  semilunar  bones.     The 

lower  end  of  the  ulna  is  very  distinct.     When  the 

hand  is  supine,   its  styloid  process  is  exposed  at 

the  inner  and  posterior  aspect  of  the  wrist  to  the 

inner    side    of    the    extensor    carpi    ulnaris.        In 

pronation,   however,   the  process  is  rendered  less 

distinct,  while  the  head  projects  prominently  on 

the  posterior  part  of  the  wrist,  and  is  found  to  lie 

between  the  tendons  of  the  extensor  carpi  ulnaris 

and  extensor  minimi  digiti. 

Wrist-joint.— The    tip    of    the    styloid    process 
of  the  ulna  corresponds  to  the  line  of  the  wrist- 


302  THE    UPPER    EXTREMITY  [Chap. 

joint,  and  a  knife  entered  below  that  point 
would  enter  the  articulation.  A  knife  entered 
horizontally  just  below  the  tip  of  the  styloid  pro- 
cess of  the  radius  would  hit  the  scaphoid  bone. 
A  line  drawn  between  the  two  styloid  processes 
would  slope  downwards  and  outwards,  its  two 
extremities  would  represent  the  extreme  inferior 
limits  of  the  radio-carpal  joint,  and  would  fairly 
correspond  to  the  chord  of  the  arc  formed  by  the 
line  of  that  joint.  The  line  between  the  styloid 
processes  would  be  nearly  |  an  inch  below  the 
summit  of  the  arch  of  the  wrist-joint. 

There  are  several  folds  in  the  skin  on  the  front 
of  the  wrist;  of  these,  the  lowest  is  the  most  dis- 
tinct. It  is  a  little  convex  downwards,  precisely 
crosses  the  neck  of  the  os  magnum  in  the  line  of 
the  third  metacarpal  bone  (Tillaux),  and  is  not 
quite  f  of  an  inch  below  the  arch  of  the  wrist 
joint.  It  is  about  J  an  inch  above  the  carpo- 
metacarpal joint,  and  indicates  very  fairly  the 
upper  border  of  the  anterior  annular  ligament 
(Fig.  65). 

Palmar  surface  of  the  hand. — The  palm  is  con- 
cave in  the  centre  where  the  skin  is  adherent  to 
the  palmar  fascia.  This  " hollow  of  the  hand"  is 
of  somewhat  triangular  outline,  with  the  apex 
upwards.  On  either  side  are  the  thenar  and  hypo- 
thenar  eminences.  At  the  upper  end  of  the  former 
eminence,  a  bony  projection  is  felt,  just  below  and 
internally  to  the  radial  styloid  process,  which  is 
formed  by  the  tubercle  of  the  scaphoid  and  ridge 
on  the  trapezium  (Fig.  65).  The  interval  separat- 
ing these  two  processes  of  bone  cannot  always  be 
made  out.  At  the  upper  extremity  of  the  hypo- 
thenar  eminence  is  the  projection  of  the  pisiform 
bone,  and  just  below  it  the  unciform  process  can 
be  identified.  Below  the  hollow  of  the  palm,  and 
opposite  the  clefts  between  the  four  fingers,  three 
little  elevations  are  seen,  especially  when  the  first 
phalanges  are  extended,  and  the  second  and  third 
are  flexed.  These  correspond  to  the  fatty  tissue 
between  the  flexor  tendons  and  the  digital  slips 


XV]  PALMAR    SURFACE    OF    HAND  303 

of  the  palmar  fascia.  The  grooves  that  may  be 
seen  to  separate  the  elevations  correspond  to  those 
slips. 

Of  the  creases  in  the  shin  of  the  palm  (Fig.  61), 
three  require  especial  notice.  The  first  starts  at 
the  wrist,  between  the  thenar  and  hypothenar 
eminences,  and,  marking  off  the  former  eminence 
from  the  palm,  ends  at  the  outer  border  of  the 
hand  at  the  base  of  the  index  finger.  The  second 
fold  is  slightly  marked.  It  starts  from  the  outer 
border  of  the  hand,  where  the  first  fold  ends. 
It  runs  obliquely  inwards  across  the  palm  with 
a  marked  inclination  towards  the  wrist,  and  ends 
at  the  outer  limit  of  the  hypothenar  eminence. 
The  third,  lowest,  and  best-marked  of  the  folds 
starts  from  the  little  elevation  opposite  the  cleft 
between  the  index  and  middle  fingers,  and  runs 
nearly  transversely  to  the  ulnar  border  of  the 
hand,  crossing  the  hypothenar  eminence  at  the 
upper  end  of  its  lower  fourth.  An  unimportant 
crease  running  obliquely  from  the  third  to  the 
second  fold  gives  to  these  markings  the  outline 
of  the  letter  M.  The  first  fold  is  produced  by  the 
opposition  of  the  thumb,  the  second  mainly  by 
the  bending  simultaneously  of  the  metacarpo- 
phalangeal joints  of  the  first  and  second  fingers, 
and  the  third  by  the  flexion  of  the  three  inner 
fingers.  The  second  fold,  as  it  crosses  the  third 
metacarpal  bone,  corresponds  approximately  to  the 
lowest  point  of  the  superficial  palmar  arch  (Fig.  61). 
The  third  fold  crosses  the  necks  of  the  metacarpal 
bones,  and  indicates  pretty  nearly  the  upper  limits 
of  the  synovial  sheaths  for  the  flexor  tendons  of  the 
three  outer  fingers  (Fig.  65).  A  little  way  below 
this  fold  the  palmar  fascia  breaks  up  into  its  four 
slips,  and  midway  between  the  fold  and  the  webs 
of  the  fingers  lie  the  metacarpo-phalangeal  joints. 
Of  the  transverse  folds  across  the  fronts  of  the 
fingers  corresponding  to  the  metacarpo-phalangeal 
and  interphalangeal  joints,  the  highest  is  single 
for  the  index  and  little  finger  and  double  for  the 
other  two.     It  is  placed  nearly  f  of  an  inch  below 


304  THE    UPPER    EXTREMITY  [Chap. 

the   corresponding   joint.     The    middle    folds    are 
double  for  all  the  fingers,  and  are  exactly  oppo- 


Fig.  61. — Surface  markings  on  the  palm  of  the  hand. 

The  thick  black  lines  represent  the  chief  creases  on  the  skin. 

site  the  proximal  interphalangeal  joints.  The 
distal  creases  are  single,  and  are  placed  a  little 
above  the  corresponding  joints   (1   to  2  mm.,   ac- 


XV]  SURFACE    OF    THE   HAND  305 

cording  to  Paulet).  There  are  two  single  creases 
on  the  thumb  corresponding  to  the  two  joints, 
the  higher  crossing  the  metacarpophalangeal 
articulation  obliquely.  The  free  edge  of  the  web 
of  the  fingers,  as  measured  from  the  palmar  sur- 
face, is  about  |  of  an  inch  from  the  metacarpo- 
phalangeal joints.  The  superficial  palmar  arch 
may  be  represented  by  a  curved  line  across  the 
palm  starting  from  the  pisiform  bone  and  run- 
ning in  a  line  with  the  palmar  border  of  the 
thumb  when  outstretched  at  right  angles  with  the 
index  finger.  The  deep  arch  is  between  \  and  \ 
an  inch  nearer  the  wrist,  and  its  position  may 
be  accurately  marked  by  a  line  drawn  from  the 
base  of  the  fifth  metacarpal  to  the  base  of  the 
second,  two  easily  distinguished  points.  The 
digital  arteries  bifurcate  about  \  an  inch  above 
the  clefts  between  the  fingers  (Fig.  61). 

Dorsal  surface  of  the  hand. — On  the  outer  side  of 
the  wrist,  when  the  thumb  is  extended,  a  hollow 
is  obvious  between  the  extensores  ossis  metacarpi 
and  brevis  pollicis  and  the  extensor  longus  pol- 
licis.  French  writers  have  termed  this  hollow 
"tabatiere  anatomique "  (Fig.  62).  Across  this 
hollow  and  beneath  the  tendons  just  named  runs 
the  radial  artery.  Under  the  skin  over  the  space 
can  usually  be  seen  a  large  vein,  the  cephalic 
vein  of  the  thumb.  Across  the  space  also  runs 
the  external  division  of  the  terminal  branch  of 
the  radial  nerve.  In  the  floor  of  the  "  snuff-box" 
are  the  scaphoid  bone  and  the  trapezium.  The 
extensor  longus  pollicis  crosses  the  apex  of  the 
first  interosseous  space.  The  sesamoid  bones  of 
the  thumb  and  the  joint  between  the  trapezium 
and  the  first  metacarpal  bone  can  all  be  well 
made  out.  The  latter  articulation  is  situate  in 
the  floor  of  the  "  tabatiere."  On  the  back  of  the 
hand  the  various  tendons  and  the  surface  veins, 
too,  can  all  be  clearly  distinguished.  Between 
the  first  and  second  metacarpal  bones  is  the  first 
dorsal  interosseous  muscle,  which  forms  a  con- 
spicuous prominence  when  the  thumb   is  pressed 


306 


THE   tJPPEK    EXTEEMITY 


[Chap. 


against  the  side  of  the  index  finger.  The  three 
rows  of  knuckles  are  formed  by  the  proximal  bones 
of  the  several  joints. 

The  skin  of  the  palm  and  of  the  front  of 
the  fingers  is  thick  and  dense,  while  that  on  the 
back  of  the  hand  is  much  finer.  The  palm, 
the    fronts    and    sides     of    the    fingers,    and    the 


Articular  (Ulna) 

Styloid  (Ulna) 

Semilunar 

Cuneiform 


BASE    OF    5TH 

Metacarp. 


Ext.  Prop-  Poll. 
Styloid  (radius) 
radial  Ridge 

Scaphoid 
Radial  Art. 
Os  Magnum  (Head) 
Trapezium 


Fig.  62. — Chief  surface  markings  on  the  dorsal   aspect  of 
the  wrist. 


dorsal  aspects  of  the  last  phalanges,  all  show 
an  entire  absence  of  hair  and  of  sebaceous 
glands.  These  parts  are,  therefore,  exempt  from 
the  maladies  that  attack  hair-follicles  and  their 
gland  appendages.  On  the  dorsum  of  the  hand, 
and  of  the  first  and  second  rows  of  phalanges, 
there  are  numerous  hairs  and  sebaceous  follicles. 
Sweat-glands  are  more  numerous  in  the  skin  of 
the  palm  than  in  any  other  part.     According  to 


XV]  SKIN    OF    THE    HAND  307 

Sappey  they  are  four  times  more  numerous  here 
than  they  are  elsewhere.  Krause  has  estimated 
that  nearly  2^800  of  these  glands  open  upon  a 
square  inch  of  the  palm.  Only  about  half  the 
number  are  found  upon  the  dorsum  of  the  hand. 
The  profuseness  with  which  the  palm  may  per- 
spire is  well  known,  and  is  very  marked  in  certain 
conditions.  The  cutaneous  nerve-supply  of  the 
hand  is  very  free.  The  nerves  present  Pacinian 
bodies,  which  are  far  more  numerous  in  the  hand 
than  in  any  other  part.  With  the  exception  of  the 
tip  of  the  tongue,  a  more  acute  degree  of  tactile 
sensibility  is  met  with  in  the  hand  than  elsewhere 
in  the  body.  The  most  sensitive  district  is  the 
palmar  surface  of  the  third  phalanx  of  the  index 
finger,  while  the  least  sensitive  to  tactile  im- 
pressions is  the  dorsum  of  the  hand.  It  may  be 
said  that  the  tips  of  the  fingers  are  about  thirty 
times  more  acute  to  the  sense  of  touch  than  is  the 
skin  of  the  middle  of  the  forearm,  which  is  among 
the  least  sensitive  portions  of  the  integument  as 
regards  tactile  influences. 

The  subcutaneous  tissue  of  the  front  of  the 
hand,  and  especially  of  the  palm,  is  scanty  and 
dense,  and  somewhat  resembles  the  subcutaneous 
tissue  of  the  scalp  in  that  the  skin  is  closely  ad- 
herent to  it,  and  the  fat  it  contains  is  arranged 
in  minute  lobules  lodged  in  lacunae.  Cutaneous 
ligaments  bind  the  skin  down  at  the  creases  of 
the  palm  and  fingers.  The  subcutaneous  tissue 
on  the  dorsum,  however,  is  lax,  and  has  but  a 
frail  association  with  the  skin.  Thus  it  follows 
that  subcutaneous  extravasations  of  blood  are 
practically  impossible  in  the  palm  and  on  the 
anterior  aspect  of  the  fingers,  while  they  may  be 
very  extensive  on  the  dorsum.  In  like  manner 
oedema  of  the  extremity  is  conspicuously  marked 
upon  the  dorsal  surface,  while  the  palm  remains 
comparatively  free  even  in  severe  cases.  The 
denseness  of  the  integuments  of  the  palm  renders 
inflammation  of  g  the  part  extremely  painful, 
owing  to  the  tension  that  is  so  readily  produced, 


308  THE    UPPER    EXTREMITY  [Chap. 

whereas  inflammation  in  the  lax  tissues  of  the 
dorsum  may  reach  some  magnitude  without  caus- 
ing great  pain.  The  palm  of  the  hand  is  well 
adapted  to  meet  the  effects  of  pressure  and  fric- 
tion. The  cuticle  is  thick,  the  skin  is  adherent, 
and  immediately  beneath  it  lies  the  dense  palmar 
fascia.  This  fascia  efficiently  protects  the  palmar 
nerves  and  the  main  vessels,  while  it  must  be 
noted  that  the  front  of  the  hand,  and  especially 
the  palm,  is  singularly  free  from  surface  veins. 
Indeed,  the  great  bulk  of  the  blood  from  the  hand 
is  returned  by  the  superficial  veins  on  the  dorsum 
of  the  fingers  and  hand.  In  like  manner,  the 
lymphatics  of  the  palm,  which  form  a  rich  sub- 
cutaneous plexus,  join  the  large  efferent  lym- 
phatics on  the  dorsum  of  the  hand. 

The  form  of  the  nail  varies  somewhat  in  in- 
dividuals, and,  according  to  certain  authors, 
there  are  special  types  of  nail  to  be  met  with  in 
some  constitutional  diseases.  By  the  Hippocratic 
hand  is  meant  a  hand  the  tips  of  the  fingers  of 
which  are  clubbed  and  the  nails  of  which  are 
much  curved.  This  condition  would  appear  to  be 
due  to  impeded  circulation  by  retardation  in  the 
return  of  venous  blood,  and  perhaps  also  to  im- 
perfect oxygenation  of  that  blood.  It  is  most 
often  met  with  in  congenital  heart  disease,  in 
phthisis,  empyema,  chronic  lung  affections,  and 
certain  thoracic  aneurysms.  There  are  several 
forms  of  inflammation  affecting  the  matrix  of  the 
nail  and  the  soft  parts  immediately  around  it 
(onychia,  paronychia).  Such  inflammations  lead 
to  great  deformity  of  the  structure  itself.  When 
a  nail  is  thrown  off  by  suppuration  or  violence 
a  new  nail  is  produced,  provided  any  of  the 
deeper  epithelial  cells  are  left.  During  conval- 
escence from  certain  illnesses  (e.g.  scarlet  fever), 
a  transverse  groove  will  appear  across  all  the 
nails.  This  groove  indicates  the  portion  of  nail 
formed  during  the  illness,  and  by  watching  its 
movement  the  rate  of  growth  of  the  nail  can  be 
estimated.     The  nail  grows  at  the  average  rate  of 


XV]  PALMAR    FASCIA  309 

sVnd  of  an  inch  per  week;  if  the  hand  is  im- 
mobilized by  splints  the  rate  of  growth  is  retarded. 
(Head.)  It  may  be  noted  that  each  digital  nerve 
gives  a  special  branch  of  large  size  to  the  pulp 
beneath  the  nail,  and  this  explains  the  intense 
pain  felt  when  a  foreign  body  is  thrust  under 
the  nail. 

The  fasciae.— Beneath  the  skin  of  the  palm  is 
the  dense  palmar  fascia.  This  fascia  gives  almost 
as  much  strength  to  the  hand  as  would  so  much 
bone,  while  its  unyielding  character,  its  com- 
parative freedom  from  vessels  and  nerves,  render 
it  well  suited  to  withstand  the  effects  of  pressure. 
The  fascia  gives  slips  to  each  finger ;  each  slip 
sends  fibres  to  join  the  digital  sheaths  of  the 
tendons,  the  skin,  and  the  superficial  transverse 
ligament.  In  the  disease  known  as  Dupuytren's 
contraction,  the  palmar  fascia,  and  especially  its 
digital  slips,  becomes  contracted.  One  or  more 
or  all  of  the  fingers  may  be  involved  in  the  con- 
traction. The  proximal  phalanx  is  drawn  or 
flexed  towards  the  palm,  and  later  the  second 
phalanx  becomes  bent.  The  skin  is  drawn  in 
towards  the  fascia,  since  the  two  structures  are 
normally  connected  with  one  another.  Experi- 
ment shows  that  by  dragging  upon  the  fascia 
the  proximal  phalanx  can  be  readily  bent,  and 
also,  but  with  less  ease,  the  middle  phalanx.  The 
middle  part  of  the  palmar  fascia  represents  the 
tendon  of  the  palmaris  longus  in  the  hand. 

The  structures  of  the  palm  are  divided  into 
three  spaces  by  the  fascia  (Fig.  63).  Thus  the 
muscles  of  the  thenar  and  hypothenar  eminences 
are  both  enclosed  in  a  thin  fascia  proper  to  each. 
The  two  spaces  formed  by  these  membranes  are 
enclosed  in  all  directions,  and  are  capable,  though 
only  in  a  feeble  way,  of  limiting  suppuration 
when  it  commences  in  them.  Between  these  two 
spaces  is  a  third  space,  which  is  roofed  in  by 
the  palmar  fascia.  This  cavity  is  closed  in  at  the 
sides,  but  is  open  above  and  below.  Above  there 
is  a  free  opening  beneath  the  annular  ligament 


310  THE    UPPER    EXTREMITY  TChap. 

and  along  the  flexor  tendons  into  the  forearm, 
while  below  there  are  the  seven  passages  provided 
for  by  the  division  of  the  palmar  fascia.  Of  these 
seven  passages,  four,  situate  at  the  roots  of  the 
several  fingers,  give  passage  to  the  flexor  tendons, 
while  the  remaining  three  correspond  to  the  webs 
between  the  fingers,  and  give  passage  to  the  lum- 


Fig.  63. — Horizontal  section  of  the  hand  through  the  middle 
of  the  thenar  and  hypothenar  eminences.     (Tillaux.) 

a,  Metacarpal  bone  ;  b,  first  dorsal  interosseous  ;  c,  palmaris  brevis 
d,  abductor  min.  digiti ;  e,  flexor  brevis  min.  dig.  :  /,  opponens 
min.  dig.  ;  g,  flexor  brevis  poll.  ;  h,  abductor  poll.  ;  /,  opponens 
poll.  ;  j,  adductor  poll.  ;  k,  flexor  long  poll.  ;  /,  dorsal  interossei ; 
m,  palmar  interossei  ;  »,  flexor  sublimis  ;  o,  flexor  profundus  ; 
p,  superflc.  vola) ;  q,  median  nerve,  and  (on  inner  side)  ulnar 
artery  and  nerve  ;  r,  deep  palmar  arch  ;  1,  palmar  fascia  ;  2,  outer 
septum  ;  3  inner  septum  ;  4,  deep  fascia  of  palm. 

bricales  and  the  digital  vessels  and  nerves.  When 
pus,  therefore,  forms  on  the  palm,  beneath  the 
palmar  fascia,  it  cannot  come  forward  through 
that  dense  membrane,  but  escapes  rather  along  the 
fingers  or  makes  its  way  up  into  the  forearm. 
So  rigid  is  the  resistance  offered  by  the  palmar 
fascia,  that  pent-up  pus  will  make  its  way  through 
the  interosseous  spaces  and  appear  on  the  dorsum 
of  the  hand,  rather  than  come  through  the  cover- 
ings of  the   palm. 


XV] 


TENDONS    OF    THE    WRIST 


311 


In  opening  a  palmar  abscess,  when  it  points 
above  the  wrist,  the  incision  should  be  in  the  long 
axis  of  the  forearm,  should  be  above  the  annular 
ligament,  and  is  most  conveniently  made  a  little 
to  the  ulnar  side  of  the  palmaris  longus,  for  a 
cut  in  this  position  would  escape  both  the  ulnar 
and  radial  arteries  and  also  the  median  nerve. 

The  tendons  about  the  wrist  are  bound  down 
and  held  in  place  by  the  annular  ligaments.     So 
dense  is  the  anterior  ligament,   that  even  in  ex- 
tensive abscess  of  the  palm  reaching 
into    the    forearm,    and    in    severe         i      a 
distension    of    the    synovial    sheaths 
beneath    the    ligament,     it    remains 
firm,  and  will  not  yield.     The  lower 
border  of  the  posterior  annular  liga- 
ment corresponds. to  the  upper  edge 
of    the    anterior    band,     and    these 
structures  together  act  the  part  of 
the  leather  bracelet  that  the  labourer 
sometimes  wears   around  his   wrist," 
and  that,  in  fact,  takes  the  function 
of  an  additional  annular  ligament. 

The  fibrous  sheaths  for  the  flexor 
tendons  extend  from  the  metacarpo- 
phalangeal joints  to  the  upper  ends 
of  the  distal  phalanges.  The  pulp 
of  the  third  phalanx,  therefore,  rests 
practically  upon  the  periosteum. 
Opposite  the  finger-joints  the  sheaths 
are  lax  and  thin,  and  spaces  may 
occur  between  the  decussating  fibres 
of  the  sheaths,  through  which  the  synovial  mem- 
brane lining  the  sheath  may  protrude.  It  is,  I 
believe,  through  this  less  protected  part  of  the 
sheath  that  external  suppuration  often  finds  its 
way  into  the  interior  of  the  sheath.  The  sheaths 
in  the  rest  of  their  course  are  dense  and  rigid, 
and  whan  cut  across  remain  wide  open  (Fig.  64). 
Thus,  after  the  division  of  the  sheath,  as  in 
amputation,  an  open  channel  is  left  leading  into 
the  palm  of  the  hand,   and  offering  the  greatest 


Fig.  64.— Ho- 
rizontal sec- 
tion through 
middle  of 
second  pha- 
lanx. {Til- 
la  ux.) 

a,  Flexor  ten- 
don; b,  fibrous 
sheath  of  ten- 
don ;  c,  exten- 
sor tendon  ;  d 
digital  artery 
and  nerve. 


312  THE    UPPER    EXTREMITY  [Chap. 

facility  for  the  spread  of  pus  into  that  part.  It 
is  this  rigidly  open  fibrous  sheath  that  probably 
may  explain  the  frequency  of  suppuration  in  the 
palm  after  amputation  of  a  part  of  a  finger,  and 
I  am  decidedly  of  opinion  that  some  steps  should 
be  taken  to  protect  or  shut  off  this  channel  in 
any  case  where  the  sheath  has  been  accidentally 
or  intentionally  divided. 

The  tendons  accurately  fill  the  fibrous  sheaths. 
A  gangliform  growth  on  the  tendon  as  it  enters 
the  sheath,  or  a  constriction  of  the  sheath  with  an 
inequality  in  the  tendon,  gives  rise  to  the  con- 
dition known  as  •'  snap  '[  finger.  Such  a  digit 
cannot  be  extended  by  will,  but  when  pushed  a 
little  way  "  springs  back  with  a  snap  like  the 
blade  of  a  pocket  knife  "  (Abbe).  "  Congenital 
contraction  ' '  of  the  little  finger  is  very  common 
in  a  slight  degree.  In  marked  cases,  the  prox- 
imal phalanx  is  hyperextended  and  the  middle 
flexed.  Lockwood  found  in  such  a  case  that  the 
condition  was  due  to  a  contraction  in  the  fibrous 
sheath  in  front  of  the  joint.  Contracted  finger 
following  whitlow  is  due  to  an  adhesion  of  the 
tendons  to  their  sheath.  Paralytic  contraction  of 
the  flexor  muscles  also  brings  about  permanent 
contracture  of  the  fingers. 

Synovial  sacs  and  sheaths.— There  are  two 
synovial  sacs  beneath  the  annular  ligament  for  the 
flexor  tendons,  one  for  the  flexor  longus  pollicis, 
the  other  for  the  flexor  sublimis  and  profundus 
tendons  (Fig.  65).  The  former  extends  up  into 
the  forearm  for  about  ij  inches  above  the  annular 
ligament,  and  follows  its  tendon  to  its  insertion 
in  the  last  phalanx  of  the  thumb.  The  latter 
rises  about  lh  inches  above  the  annular  band, 
and  ends  in  diverticula  for  the  four  fingers.  The 
process  for  the  little  finger  usually  extends  to  the 
insertion  of  the  flexor  profundus  tendon  in  tKe 
last  phalanx.  The  remaining  three  diverticula 
end  about  the  middle  of  the  corresponding  meta- 
carpal bones.  The  synovial  sheaths  for  the  digital 
part  of  the  tendons  to  the  index,  middle,  and  ring 


XVI 


SYNOVIAL    SACS    OF    WBIST 


313 


fingers  end  above  about  the  neck  of  the  meta- 
carpal bones,  and  are  thus  separated  by  about  \ 
to  \  an  inch  from  the  great  synovial  sac  beneath 
the  annular  ligament.  Thus  there  is  an  open 
channel  from  the  ends  of  the  thumb  and  little 
finger  to  a  point  in  the  forearm  some  \\  inches 


Flexor    Diqitorum 

Unciform 

Pisiform 

Wrist  Folds 

Styloid  Process 


Flex.  Longus  Pollicis 

Trapezium 
Ant.  Annular  Ligavent 
scaphoid 

flexor  Carp.  Radialis 
styloid  Process 


Fig.    65.  — Anterior   annular    ligament    of    the    wrist,   and 
synovial  sheaths  of  the  wrist  and  hand. 

The  creases  of  the  hand  are  indicated  by  black  lines  ;  the  synovial 
sheaths  are  shown  in  red. 

above  the  annular  ligament.  The  arrangement 
explains  the  well-known  surgical  fact  that  ab- 
scesses of  .the  thumb  and  little  finger  are  apt  to  be 
followed  by  t  abscesses  in  the  forearm,  while  such 
a  complication  is  not  usual  after  suppuration  in 
the  remaining  fingers.  The  synovial  sac  for  the 
flexor  tendons  is  narrowed  as  it  passes  beneath 
the   annular  ligament,    and  thus  it   happens   that 


314  THE    TIPPER    EXTREMITY  [Chap. 

when  distended  with  fluid  or  with  pus,  it  presents 
an  hour-glass  outline,  the  waist  of  the  hour-glass 
corresponding  to  the  ligament.  The  two  synovial 
sacs  beneath  the  ligament  sometimes  communicate 
with  one  another.  The  tendon  of  the  flexor  carpi 
radialis  perforates  the  insertion  of  the  annular 
ligament  to  the  trapezium ;  it  is  surrounded  by  a 
synovial  sheath   (Fig.   65). 

In  one  form  of  whitlow,  that  form  where  the 
pus  occupies  the  synovial  sheaths  of  the  tendons 
on  the  fingers  (thecal  abscess),  the  suppuration 
can  often  be  seen  to  end  abruptly  where  the  sheath 
ends,  when  the  index,  middle,  or  ring  finger  is 
involved,  viz.  opposite  the  neck  of  the  corre- 
sponding metacarpal  bones.  In  another  form  of 
whitlow  (the  abscess  in  the  pulp  at  the  end  of  the 
finger)  the  periosteum  of  the  third  phalanx  is 
readily  attacked,  there  being  no  intervening  ten- 
don sheath  over  that  bone.  In  this  affection  the 
bone  often  necroses  and  comes  away,  but  it 
significant  to  note  that  it  is  very  seldom  that  the 
whole  of  the  phalanx  perishes.  The  upper  part, 
or  base,  of  the  bone  usually  remains  sound,  and  is 
probably  preserved  by  the  insertion  of  the  flexor 
profundus  tendon.  The  base  of  the  bone  is  an 
epiphysis  that  does  not  unite  to  the  shaft  until 
the  eighteenth  or  twentieth  year. 

The  tendons  do  not  lie  free  within  the  sac,  but 
are  bound  to  it  by  folds  of  synovial  membrane  in 
much  the  same  way  as  the  bowel  is  bound  to  the 
abdominal  parietes  by  its  mesentery.  These  folds 
may  be  ruptured  in  severe  sprains,  when  the 
nutrient  vessels  for  the  tendon,  which  are  con- 
tained in  them,  may  be  torn.  Eupture  is  followec 
by  effusion  into  the  sac.  These  folds  are  almost 
absent  within  the  digital  sheaths,  the  slight  liga- 
menta  longa  and  brevia,  near  the  insertion  oi 
the  tendons,  being  their  sole  representatives.  Syn- 
ovial sacs  are  lined  by  a  squamous  epithelium,  anc 
have  extremely  free  communication  with  the  lym- 
phatic vessels  of  the  part.  Hence  the  f ree^  absorp- 
tion of  infective  matter  from  such  cavities. 


XV]  SYNOVIAL    SHEATHS    OF    WRIST  3l5 

Beneath  the  posterior  annular  ligament  there 
are  six  synovial  sheaths  for  tendons,  correspond- 
ing to  the  six  canals  formed  by  that  ligament. 
The  sheath  most  frequently  inflamed  is  that  for 
the  extensores  ossi  metacarpi  and  brevis  pollicis. 
It  runs  from  a  point  about  }  of  an  inch  above  the 
radial  styloid  process  to  the  first  carpo-meta- 
carpal  joint.  The  other  sheaths  reach  above  to 
the  upper  border  of  the  annular  ligament,  that 
for  the  two  radial  extensors,  however,  beginning 
about  \  an  inch  above  the  ligament.  The  sheaths 
for  the  extensor  communis  and  the  extensor 
minimi  digiti  extend  below  to  the  middle  of  the 
metacarpus;  that  for  the  extensor  indicis  barely 
reaches  the  metacarpus.  The  other  sheaths  follow 
the  tendons  to  their  insertions.  The  synovial  lin- 
ing and  folds  of  these  sheaths  are  injured  in 
Colles'  fracture  of  the  radius.  The  tendons  be- 
come adherent  and  fixed  to  their  sheaths  unless 
this  be  prevented  by  passive  movements  of  the 
tendons. 

Blood-vessels  and  lymplmfies*— The  hand 
is  very  well  supplied  with  blood,  and  indeed  the 
finger  pulp  is  one  of  the  most  vascular  parts  in 
the  body.  Cases  are  recorded  where  the  tip  of 
the  finger  has  been  accidentally  cut  off,  and  has 
grown  again  to  the  limb  on  being  immediately 
reapplied.  The  position  of  the  palmar  arches 
has  been  pointed  out.  It  is  well  known  that 
haemorrhage  from  either  of  the  palmar  arches  can- 
not be  checked  by  ligature  of  the  radial  or  ulnar 
artery  alone,  on  account  of  the  connexion  of  the 
arches  with  those  vessels;  and  it  is  also  known 
that  simultaneous  ligation  of  the  two  vessels  may 
have  no  better  effect,  owing  to  the  anastomoses 
between  the  palmar  arches  and  the  interosseous 
vessels.  The  anastomosis  between  the  two  palmar 
arches  is  well  known,  and  is  freely  established 
both  by  the  main  vessels  themselves  and  by  the 
communion  that  exists  between  the  digital  arteries 
from  the  superficial  arch  and  the  palmar  inter- 
osseous   branches    from    the    deeper    vessels.        In 


316  THE    UPPER    EXTREMITY  [Chap. 

bleeding  from  the  palm,  the  simultaneous  ligature 
of  the  radial  and  ulnar  arteries  may  also  entirely 
fail  in  those  cases  where  the  arches  are  freely 
joined,  or  are  more  or  less  replaced  by  large  and 
abnormal  interosseous  vessels,  or  by  a  large 
tk  median  "  artery.  When  either  the  radial  or  the 
ulnar  part  of  the  arches  is  defective,  the  lack  is 
usually  supplied  by  the  other  vessel ;  and  it  is 
well  to  note  that  the  deficiency  is  most  common 
in  the  superficial  or  ulnar  arch.  Pressure  ap- 
plied to  the  palm  to  arrest  bleeding  is  apt  to  cause 
gangrene,  owing  to  the  rigidity  of  the  parts  and 
the  ease  with  which  considerable  pressure  can  be 
applied. 

The  radial  artery,  as  it  curves  round  the  back 
of  the  hand  to  reach  the  deeper  part  of  the  palm, 
is  in  close  contact  with  the  carpo-metacarpal 
joint  of  the  thumb  (Fig.  62).  This  fact  must  be 
borne  in  mind  in  amputation  of  the  entire  thumb, 
and  also  in  resection  of  the  first  metacarpal  bone. 
The  superficialis  volae,  if  large,  may  bleed  seri- 
ously. It  adheres  to  the  surface  of  the  annular 
ligament,  and  may  therefore  be  difficult  to  pick 
up  when  wounded. 

From  the  larger  size  and  great  number  of  the 
lymphatics  about  the  fingers  and  on  the  dorsum  of 
the  hand,  it  follows  that  lymphangitis  is  more 
common  after  wounds  of  those  parts  than  it  is 
after  wounds  of  the  palm. 

Bones  and  joints. — The  inferior  radio-ulnar 
joint  is  supported  by  the  powerful  triangular 
fibro-cartilage,  which  forms  the  strongest  and 
most  important  of  all  the  ligamentous  connexions 
between  the  two  bones.  The  synovial  sheath  of 
the  extensor  minimi  digiti  sometimes  communi- 
cates with  this  joint,  and  may  therefore  be  involved 
when  that  articulation  is  diseased. 

The  strength  of  the  wrist-joint  depends  not  so 
much  upon  its  mechanical  outline  or  its  liga- 
ments as  upon  the  numerous  strong  tendons  that 
surround  it,  and  that  are  so  closely  bound  down 
to  the  bones  about  the  articulation.     Moreover,  in 


XVI  MOVEMENTS    AT    THE    WRIST  317 

the  case  of  the  wrist  the  long  lever  does  not  exist 
on  the  distal  side  of  the  joint.  The  anterior  liga- 
ment of  the  wrist  is  the  strongest  ligament  of  the 
joint,  while  the  posterior  is  the  weakest.  The 
former  structure  limits  extension,  and  the  latter 
flexion ;  and  in  connexion  with  this  arrangement 
it  is  interesting  to  note  that  injury  from  forced 
extension  is  more  common  than  from  forced 
flexion.  Thus,  when  a  man  falls  upon  the  hand, 
he  more  usually  falls  upon  the  palm  (forced  ex- 
tension) than  upon  the  dorsum  (forced  flexion). 
Owing  to  the  thinness  of  the  posterior  ligament, 
together  with  the  more  superficial  position  of  the 
hinder  part  of  the  joint,  it  follows  that  the  effu- 
sion in  wrist-joint  disease  is  first  noticed  at  the 
back  of  the  hand. 

Movements  at  the  wrist  take  place  as  freely 
in  the  intercarpal  joint  (between  the  first  and 
second  row  of  carpal  bones)  as  in  the  radio-carpal 
joint  (Fig.  62).  The  axis  of  the  radio-carpal  joint 
is  such  that  in  flexion  the  palm  turns  towards  the 
ulnar  side  of  the  forearm;  while  in  flexion  at  the 
mid-carpal  joint  the  palm  moves  towards  the  radial 
side.  When  movement  takes  place  at  both  joints 
these  tendencies  are  balanced  and  pure  flexion 
is  produced.  The  tendon  of  the  extensor  carpi 
ulnaris  is  placed  anteriorly  to  the  axis  of  the 
mid-carpal  joint,  but  behind  the  radio-carpal,  and 
therefore  produces  flexion  in  one  joint  and  exten- 
sion in  the  other  (Ashdowne).  The  muscles  which 
act  on  the  wrist  exemplify  the  various  parts  which 
muscles  play  in  producing  a  purposeful  move- 
ment. A  muscle  may  act  as  (1)  a  prime  mover,  (2) 
an  antagonist,  (3)  a  synergic  muscle,  (4)  a  fixation 
muscle.  For  instance,  when  the  fingers  are  flexed  : 
the  deep  and  superficial  flexors  are  the  prime 
movers ;  the  antagonists  in  action  are  the  exten- 
sors of  the  fingers ;  the  flexors  of  the  fingers  would 
also  produce  flexion  at  the  wrist  were  not  the  ex- 
tensors of  the  wrist  also  thrown  into  action  as 
synergic  muscles ;  when  the  extensors  of  the  fingers 
act,  the  flexors  of  the  wrist  contract;  in  flexing 


318  THE    UPPER    EXTREMITY  [Chap. 

and  extending  the  fingers  the  wrist  can  be  rem 
dered  immovable  by  the  flexors  and  extensors  of 
the  carpus,  which  then  act  as  muscles  of  fixation. 
Thus  a  movement  which  appears  simple  results 
from  the  action  of  groups  of  muscles,  and  it  is 
this  complexity  which  makes  the  diagnosis  of 
nerve  lesions  from  a  study  of  the  action  of  mus- 
cles so  difficult.  What  has  been  said  of  the  muscles 
of  the  wrist  applies  equally  to  all  the  muscles 
of  the  body.  {See  Beevor's  Croonian  Lectures, 
1903.) 

But  little  movement  is  allowed  in  the  carpo- 
metacarpal joints  of  the  first  three  fingers,  but 
in  the  like  joints  of  the  thumb  and  little  finger 
movements  are  free,  and  their  preservation  is  of 
great  importance  to  the  general  usefulness  of  the 
hand.  The  glenoid  ligaments  in  front  of  the  three 
finger-joints  are  firmly  attached  to  the  distal  bone, 
and  but  loosely  to  the  proximal.  Thus  it  happens 
that  in  dislocation  of  the  distal  bone  backwards, 
the  glenoid  ligament  is  carried  with  it,  and  offers 
a  great  obstacle  to  reduction.  In  flexing  the 
middle  and  distal  phalanges  alone,  it  will  be  seen 
that  the  proximal  phalanx  is  steadied  by  the 
extensor  tendon  as  a  preliminary  measure ;  and 
in  paralysis  of  the  extensors,  flexion  of  these  two 
joints  alone  is  not  possible. 

Very  few  persons  have  the  power  of  flexing  the 
last  finger-joint  without  at  the  same  time  bending 
the  articulation  above  it;  but  in  certain  inflam- 
matory affections  about  the  last  phalanges  the 
terminal  joint  is  sometimes  seen  to  be  fixed  in  a 
flexed  posture  while  the  other  finger-joints  are 
straight.  In  the  condition  known  as  "  mallet  " 
finger  the  distal  phalanx  is  fixed  in  a  flexed  posi- 
tion. The  condition  is  due  to  a  partial  or  com- 
plete rupture  of  the  extensor  tendon  of  the  finger, 
commonly  the  result  of  a  blow  over  the  terminal 
knuckles. 

Colles'  fracture. — This  name  is  given  to  a  trans- 
verse fracture  through  the  lower  end  of  the  radius, 
from  J  to  1  inch  above  the  wrist-joint  (Fig.  66). 


XV] 


COLLES'    FRACTURE 


319 


It  is  associated  with  a  certain  definite  deformity, 
and  is  always  the  result  of  indirect  violence,  a 
fall  upon  the  outstretched  hand.  There  are  good 
reasons  why  the  bone  should  break  in  this  situa- 
tion. The  lower  end  of  the  radius  is  very  can- 
cellous, while  the  shaft  contains  a  good  deal  of 
compact  bone.  At  about  j  of  an  inch  from  the 
articular  surface  these  two  parts  of  the  bone  meet, 


jFRACTURED   STYLOID 


Fractured  Scaphoid 


Fig.  66. — Diagram  showing  the  situation  of  Colles'  fracture 
of  the  radius,  with  fracture  of  the  styloid  of  the  ulna. 
The  usual  position  of  a  fracture  of  the  scaphoid  is  also 
indicated. 

and  their  very  unequal  density  greatly  tends  to 
localize  the  fracture  in  this  situation.  As  to  the 
mechanism  of  this  lesion,  many  different  opinions 
are  still  held,  and  a  vast  deal  has  been  written 
on  the  subject.  I  subjoin  Professor  Chiene's  ac- 
count of  this  lesion,  because  it  may  be  taken  as 
representing  with  admirable  clearness  the  views 
most  generally  accepted  at  the  present  time  as  to 
the   nature   of   this   injury.     Into   the    discussion 

Kself  I  do  not  propose  to  enter.     The  deformity 


320  THE    UPPER    EXTREMITY  [Chap. 

in  Colles'  fracture  is  entirely  due  to  the  displace- 
ment of  the  lower  fragment. 

u  The  displacement  is  a  triple  one  :  (a)  backwards,  as 
regards  the  anteroposterior  diameter  of  the  forearm  ;  (b) 
rotation  backwards  of  the  carpal  surface  on  the  transverse 
diameter  of  the  forearm  ;  (e)  rotation  through  the  arc  of  a 
circle,  the  centre  of  which  is  situated  at  the  ulnar  attachment 
of  the  triangular  ligament,  the  radius  of  the  circle  being  a 
line  from  the  ulnar  attachment  of  the  triangular  ligament  to 
the  tip  of  the  styloid  process  of  the  radius.  (•/)  When  a 
person  in  falling  puts  out  his  hand  to  save  himself,  at  the 
moment  the  hand  reaches  the  ground  the  force  is  received 
principally  by  the  ball  of  the  thumb,  and  passes  into  the 
carpus,  and  thence  into  the  lower  end  of  the  radius.  If,  at 
the  moment  of  impact,  the  angle  between  the  axis  of  the 
forearm  and  the  ground  is  less  than  60°,  the  line  representing 
the  direction  of  the  force  passes  upwards  in  front  of  the  axis 
of  the  forearm  ;  the  whole  shock  is  therefore  borne  by  the 
lower  end  of  the  radius,  which  is  broken  off,  and,  the  force 
being  continued,  the  lower  fragment  is  driven  backwards. 
When  at  the  moment  of  impact  the  angle  is  greater  than  60°, 
the  line  of  the  force,  instead  of  passing  in  front  of  Che  axis 
of  the  arm,  passes  up  the  arm,  and  the  usual  result  is  either 
a  severe  sprain  of  the  wrist  or  a  dislocation  of  the  bones  of 
the  forearm  backwards  at  the  elbow- joint,  (b)  The  carpal 
surface  of  the  radius  slopes  forwards,  and  therefore  the 
posterior  edge  of  the  bone  receives  the  greater  part  of  the 
shock  ;  there  is,  as  a  result,  rotation  of  the  lower  fragment 
backwards  on  the  transverse  diameter  of  the  forearm,  (c) 
The  carpal  surface  of  the  radius  slopes  downwards  and 
outwards  to  the  radial  edge  of  the  arm  ;  therefore  the  radial 
edge  of  the  bone  receives  the  principal  part  of  the  shock 
through  the  ball  of  the  thumb.  As  a  result,  this  edge  of  the 
lower  fragment  is  displaced  upwards  to  a  greater  extent 
than  the  ulnar  edge  of  the  fragment,  which  remains  firmly 
attached  to  the  ulna  by  the  triangular  ligament." 

In  over  50  per  cent,  of  cases,  the  styloid  process 
of  the  ulna  is  also  broken  by  the  force  transmitted 
to  it  through  the  triangular  fibro-cartilage  (Mor- 
ton). By  means  of  this  rotatory  displacement,  the 
tips  of  the  two  styloid  processes  come  to  occupy  the 
same  level,  or  the  radial  process  may  even  mount 
above  the  ulnar.     In   nearly  every  case  there  is 


XV]  COLLES'    FRACTURE  321 

some  penetration  of  the  fragments,  the  compact 
tissue  on  the  dorsal  aspect  of  the  upper  fragment 
being  driven  (by  a  continuation  of  the  force  that 
broke  the  bone)  into  the  cancellous  tissue  on  the 
palmar  aspect  of  the  lower  fragment.  It  is  only 
in  very  rare  instances  that  the  fragments  are  so 
separated  as  to  ride  the  one  over  the  other.  In 
such  cases  the  radio-ulnar  ligaments  are  probably 
ruptured,  and  the  wrist  ceases  to  present  the  typi- 
cal deformity  of  a  Colles'  fracture.  In  studying 
the  radiographs  of  170  cases  diagnosed  as  Colles' 
fracture,  Dr.  R.  Morton  found  there  was  disloca- 
tion as  well  as  fracture  in  3  and  separation  of 
the  lower  radial  epiphysis  in  11  cases.  This 
epiphysis  is  often  separated  by  accidental  vio- 
lence. It  joins  the  shaft  about  the  twentieth  year. 
Its  junction  with  the  shaft  is  represented  by  a 
nearly  horizontal  line,  and  the  epiphysis  includes 
the  facet  for  the  ulna  and  the  insertion  of  the 
supinator  longus. 

Since  the  introduction  of  radiographic  methods 
of  examination,  it  has  been  found  that  many  in- 
juries, formerly  regarded  as  mere  sprains,  were 
really  due  to  fracture  or  displacement  of  carpal 
bones  or  fracture  of  a  metacarpal. 

Fracture  of  the  scaphoid  occurs  as  the 
result  of  falls  on  the  outstretched  palm,  or  by 
direct  violence.  It  lies  in  the  floor  of  the  "snuff- 
box," and  may  be  palpated  there.  The  semilunar 
is  most  frequently  displaced,  and  of  the  meta- 
carpal bones  the  fifth  is  most  frequently  fractured. 

Dislocations.  1.  At  the  wrist-joint.— So  strong 
is  this  articulation,  for  the  reasons  above  given, 
that  carpo-radial  luxations  are  extremely  rare. 
For  the  same  reasons,  when  they  do  occur  they 
are  usually  complicated,  and  are  associated  with 
tearing  of  the  skin,  or  rupture  of  tendons,  or 
fractures  of  the  adjacent  bones.  The  luxations  of 
the  carpus  may  be  either  backwards  or  forwards, 
the  latter  being  extremely  rare.  They  would 
appear  to  be  produced  with  equal  ease  by  a  fall 
upon  either  the  front  or  the  back  of  the  hand. 


322  THE    UPPER    EXTREMITY  [Chap. 

Bransby  Cooper  gives  the  case  of  a  lad  who  fell 
upon  the  outstretched  palms  of  both  his  hands  : 
both  wrists  were  dislocated,  one  backwards,  the 
other  forwards. 

There  are  five  articular  synovial  cavities  con- 
nected with  the  carpus.  They  occur  in  the  follow- 
ing situations  :  (a)  Between  the  carpus  and  fore- 
arm bones;  it  may  communicate  with  the  lower 
radio-ulnar  cavity  through  the  triangular  fibro- 
cartilage ;  (h)  between  the  unciform  and  the 
fourth  and  fifth  metacarpals;  (c)  between  the 
metacarpal  of  the  thumb  and  trapezium;  (d) 
between  all  the  carpal  bones  and  extending  to  the 
carpo-metacarpal  joints  of  the  second  and  third 
digits;  (e)  between  the  pisiform  and  cuneiform 
bones.  Hernial  protrusions  and  gangliform 
growths  from  these  synovial  membranes  are  fre- 
quently seen  on  the  dorsum  of  the  carpus. 

2.  Dislocation  of  the  os  magnum. — In  forcible 
flexion  of  the  hand,  the  os  magnum  naturally 
glides  backwards  and  projects  upon  the  dorsum. 
In  very  extreme  flexion  (as  in  falls  upon  the 
knuckles  and  dorsum  of  the  metacarpus),  this 
movement  of  the  bone  backwards  may  be  such 
asto  lead  to  its  partial  dislocation,  the#  luxation 
being  associated  with  some  rupture  of  ligaments. 
In  one  recorded  case  this  luxation  was  produced 
by  muscular  force.  The  patient,  a  lady,  while  in 
labour,  "seized  violently  the  edge  of  her  mattress, 
and  squeezed^  it  forcibly."  Something  was  felt 
to  give  way  in  the  hand,  and  the  head  of  the  os 
magnum  was  found  to  be  dislocated  backwards. 

3.  Dislocations  at  the  metacarpophalangeal  joint 
of  the  thumb. — In  this  luxation  the  phalanx  is 
usually  displaced  backwards,  and  the  lesion  is  of 
interest  on  account  of  the  great  difficulty  often 
experienced  in  reducing  the  bone.  Many  ana- 
tomical  reasons  have  been  given  to  explain  this 
difficulty — these  are  well  summarized  by  Hamil- 
ton in  the  following  passage  :  "  Hey  believes  the 
resistance  ^  to  be  in  the  lateral  ligaments,  be- 
tween   which    the   lower   end    of   the   metacarpal 


XV  AVULSION    OF    FINGERS  323 

bone  escapes  and  becomes  imprisoned.  Ballingall, 
Malgaigne,  Erichsen,  and  Vidal  think  the  meta- 
carpal bone  is  locked  between  the  two  heads  of 
the  flexor  brevis,  or,  rather,  between  the  oppos- 
ing sets  of  muscles  which  centre  in  the  sesamoid 
bones,  as  a  button  is  fastened  into  a  button-hole. 
Pailloux  and  others  affirm  that  the  anterior  liga- 
ment, being  torn  from  one  of  its  attachments, 
falls  between  the  joint  surfaces,  and  thus  inter- 
poses an  effectual  obstacle  to  reduction.  Lisfranc 
found  in  an  ancient  luxation  the  tendon  of  the 
long  flexor  so  displaced  inwards,  and  entangled 
behind  the  extremity  of  the  bone,  as  to  prevent 
reduction."  Mr.  Jonathan  Hutchinson  has  in- 
vestigated several  cases  and  found  that  reduc- 
tion is  prevented  by  the  fibrocartilaginous  plate 
on  the  palmar  aspect  of  the  joint.  The  plate 
is  firmly  attached  to  the  phalanx  and  is  dis- 
located with  it.  When  subcutaneously  divided 
from  the  extensor  aspect  of  the  thumb,  the  dis- 
location may  be  reduced  with  ease. 

Avulsion  of  one  or  more  fingers  may  be 
effected  by  severe  violence.  In  such  cases  the 
finger  torn  off  usually  takes  with  it  some  or  all 
of  its  tendons.  These  tendons  are  practically 
drawn  out  of  the  forearm,  and  may  be  of  con- 
siderable length.  Billroth  figures  #  a  case  where 
the  middle  finger  was  torn  out,  taking  with  it  the 
two  flexor  and  extensor  tendons  in  their  entire 
length.  When  one  tendon  only  is  torn  away 
with  the  finger,  it  is  usually  that  of  the  flexor 
profundus. 

Amputation  at  the  wrist-joint  by  the  cir- 
cular method.* — In  the  dorsal  wound  will  be  cut  the 
following  tendons  :  the  extensores  longus,  indicis, 
communis,  minimi  digiti,  and  ulnaris,  the  radial 
nerve,  and  the  dorsal  branch  of  the  ulnar  nerve. 
Thetwo  radial  extensors  will  be  cut  short  in  the 
radial  angle  of  the  wound,  as  will  also  be  the  ex- 
tensores ossis  and  brevis.    The  radial  artery  will  be 

*  See  "Manual  of  Operative  Surgery,"  by  Sir  Frederick  Treves,  Bart., 
G.C.V.O.,  C.B.,  and  Jonathan  Hutchinson,  F.R.C.S.     1910. 


324  THE    UPPER    EXTREMITY  [Chap. 

divided  close  to  the  radius.  In  the  palmar  wound 
will  be  found  the  ulnar  artery,  the  superficialis 
volse,  the  ulnar  and  median  nerves,  the  opponens, 
flexor  brevis,  and  abductor  pollicis  in  part,  the 
flexor  brevis,  opponens,  and  abductor  minimi 
digiti  in  part  (the  bulk  of  the  opponens  being 
left  behind  on  the  hand),  and  the  tendons  of  the 
flexor  sublimis  and  flexor  carpi  radialis.  The  ten- 
dons of  the  flexor  profundus  and  flexor  longus 
pollicis  are  usually  cut  short  close  to  the  bones. 

Amputation  of  the  thumb  at  the  carpo- 
metacarpal joint  by  flaps.  In  the  palmar  flap 
will  be  cut  the  abductor,  the  short  and  long 
flexor,  the  opponens,  and  the  adductor  pollicis. 
The  extensores  ossis  and  brevis  will  be  cut  short 
in  the  posterior  angle  of  the  flap.  The  extensor 
longus  and  a  considerable  portion  of  the  abductor 
indicis  will  be  found  in  the  dorsal  flap.  The 
vessels  divided  will  be  the  two  dorsal  arteries 
of  the  thumb  and  theprinceps  pollicis.  There  is 
great  danger,  in  this  operation,  of  wounding 
the  radialis  indicis  and  the  radial  artery  itself 
where  it  begins  to  dip  into  the  palm. 

Nerve  supply  of  the  upper  limb. — The 
symptoms  which  follow  a  lesion  to  the  nerves  of 
the  upper  limb  depend  on  the  point  injured. 
If  the  fifth  spinal  nerve  be  crushed  between  its 
origin  in  the  spinal  cord  and  its  exit  from  the 
intervertebral  foramen,  either  from  fracture  or 
caries  of  the  cervical  vertebrae,  the  injury  is  fol- 
lowed by  paralysis,  partial  or  complete,  of  the 
rhomboids,  spinati,  deltoid,  biceps,  brachialis 
anticus,  and  supinator  longus,  but  strangely 
enough  the  lesion  is  not  accompanied  by  loss  of 
sensation.  Perhaps  the  fact  that  the  posterior 
root  of  the  fifth  cervical  nerve  is  very  small  may 
assist  to  explain  this  fact  (W.  Harris).  Injury 
to  the  cord  just  above  the  origin  of  the  eighth 
cervical  vertebra  will  leave  the  skin  of  the  ulnar 
half  of  the  arm  anaesthetic,  while  the  muscles  of 
the  fingers,  hand,  and  wrist,  and  some  of  those  at 
the  elbow  and  shoulder,   will  be  paralysed.     The 


XVJ         NEEVE    SUPPLY    OF    UPPER    LIMB         325 

fibres  for  the  innervation  of  the  various  groups 
of  arm  muscles  pass  out  in  quite  an  orderly  man- 
ner by  the  fifth  cervical  to  the  first  dorsal  nerve 
from  corresponding  segments  of  the  cord.  Those 
for  the  abductors  of  the  shoulder  pass  out  by  the 
fifth;  for  the  adductors  by  the  sixth  and  seventh; 
for  the  flexors  of  the  elbow  by  the  fifth  and 
sixth ;  for  the  extensors  by  the  seventh  and  eighth ; 
for  the  extensors  of  the  wrist  and  fingers  by  the 
sixth  and  seventh;  and  those  for  the  flexors  by 
the  eighth  and  first  dorsal.  It  is  important  to  re- 
member that  a  cervical  spinal  nerve  makes  its  exit 
from  the  canal  opposite  the  origin  of  the  next 
spinal  nerve.  Further,  the  nerve  to  each  muscle 
is  made  up  of  fibres  derived  from  two  or  more 
spinal  nerves. 

The  following  is  Dr.  Herringham's  account  of 
the  usual  spinal  origin  of  the  fibres  in  the  nerves 
of  the  upper  limb,  and  of  the  usual  supply  of  the 
chief  muscles.  (The  figures  indicate  the  fifth, 
sixth,  seventh,  and  eighth  cervical  nerves,  and  the 
first  dorsal  nerve.) 

Nerves. — Nerve  of  Bell,  5,  6,  7 ;  suprascapular, 
5  or  5,  6 ;  external  cutaneous,  5,  6,  7 ;  internal 
cutaneous,  1  or  8,  1 ;  nerve  of  Wrisberg,  1 ;  circum- 
flex, 5,  6 ;  median,  6,  7,  8,  1 ;  ulnar,  8,  1 ;  musculo- 
spiral,  6,  7,  8,  or  5,  6,  7,  8. 

Muscles. — 3,  4,  5,  lev.  anguli  scap. ;  5,  rhom- 
boids; 5  or  5,  6,  biceps,  brachialis  ant.,  supra- 
and  infraspinatus,  teres  minor ;  5,  6,  deltoid,  sub- 
scapulars; 6,  teres  major,  pronator  teres,  flexor 
carpi  rad.,  supin.  longus  and  brevis,  superficial 
thenar  muscles;  5,  6,  7,  serratus  magnus;  6  or  7, 
extensores  carpi  rad. ;  7,  coraco-brachialis,  latiss. 
dorsi5>  extensors  at  back  of  forearm,  outer  head 
of  triceps;  7, ^  8,  inner  head  of  triceps;  7,  8,  1, 
flexor  sublimis,  flexores  profund.,  carpi  uln., 
long,  poll.,  pronator  quad. ;  8,  long  head  of  tri- 
ceps, hypothenar  muscles,  interossei,  deep  thenar 
muscles. 

In  the  cutaneous  nerve  supply  of  the  fingers, 
it  must  be  remembered  that  on  the  palmar  aspect 


326 


THE    UPPER    EXTREMITY 


[Chap. 


!  7 


!  7 


Fig.  67. — Cutaneous 
nerve  supply  of 
upper  limb. 


0    |  10 


V 


Anterior  aspect :  1,  Cervical  plexus  ;  2,  circumflex  ;  3,  ext.  cut.  of  muse 

spiral :  4,  ext.  cutaneous  ;  5,  median  ;  G,  ulnar  ;  7,  int.  cutaneous  ; 

8,  n.  of  Wrisberg. 
Posterior  aspect :  1,  Cervical  plexus  :  2,  circumflex  ;  3,  int.  cut.  of  muse. 

spiral ;  4,intercosto-humeral ;  5,n.  of  Wrisberg ;  6,  int.  cutaneous  ; 

7  ext.  cut.  of  muse,  spiral :  8  ext.  cutaneous  ;  9  ulnar  ;  10,  radial. 


XVJ    NERVE  SUPPLY  OF  UPPEK  LIMB 


\m 


Fig.   68. — Showing    the  sensory  distribution  of  the  spinal 
nerves  in  the  upper  limb. 

The  dotted  lines  indicate  approximately  the  area  of  each  nerve.  No 
attempt  is  made  to  show  the  extent  to  which  the  root  areas 
overlap.    (For  the  nerves  supplying  each  area  see  Fig.  67.) 


328  THE    UPPER    EXTREMITY  [Chap. 

the  thumb,  the  two  outer  fingers,  and  the  radial 
side  of  the  ring  linger  are  supplied  by  the  median, 
the  remaining  one  and  a  half  fingers  by  the  ulnar 
(Fig.  67).  On  the  dorsal  aspect,  the  thumb  is 
supplied  by  the  radial;  the  index  and  middle 
fingers  are  supplied  (as  far  as  the  base  of  the 
second  phalanx)  by  the  radial,  and  over  the 
second  and  third  phalanges  by  the  median.  The 
little  finger  and  the  ulnar  side  of  the  ring  finger 
are  supplied  by  the  ulnar.  The  radial  side  of 
the  ring  finger,  as  far  as  the  base  of  the  second 
phalanx,  is  supplied  by  the  radial,  and  the  rest  of 
this  side  of  the  digit  by  the  median  (Fig.  67). 
The  cleft  between  the  middle  and  ring  fingers  is 
occasionally  supplied  by  the  ulnar,  or  partly  by 
the  ulnar  and  partly  by  the  radial.  The  roots 
and  spinal  segments  to  which  these  nerves  belong 
may  be  ascertained  from  Fig.  68.  The  roots  are 
distributed  in  order  of  origin,  the  fifth  cervical 
beginning  on  the  radial  or  outer  side  of  the 
shoulder,  and  the  second  dorsal,  or  sometimes  the 
third,  ending  on  the  ulnar  or  inner  aspect  of 
the  upper  arm.  The  hand  is  mainly  supplied 
by  the  seventh.  The  neighbouring  spinal  nerves, 
as  is  also  the  case  with  ordinary  terminal  branches, 
overlap  widely  in  their  distribution.  The  area  of 
anaesthesia  is  much  less  than  the  area  of  anatomi- 
cal distribution.  The  nerves  along  the  ulnar  side 
of  the  arm  are  derived  from  cord  segments  which 
also  give  off  sympathetic  (sensory)  nerves  to  the 
heart;  in  angina  pectoris  the^  heart  is  really  the 
cause  of  the  pain,  but  the  patient  feels  it  on,  and 
refers  it  to,  the  ulnar  side  of  the  arm. 

Paralysis  of  the  lower  trunk  of  the  brachial 
plexus. — Mention  has  already  been  made  of  a 
partial  paralysis  of  the  arm  in  cases  where  a 
cervical  rib  is  present  (see  p.  176).  The  paralysis, 
which  usually  begins  to  appear  soon  after  adult 
life  is  reached,  and  oftener  in  women  than  in 
men,  is  due  to  the  pressure  of  the  lowest  trunk 
of  the  brachial  plexus  on  the  rib ;  hence  the 
distribution  of  the  ulnar  nerve  is  the  area  most 


XV]    PAEALYSIS    OF    THE    MUSCULO-SPIKAL     329 

affected.  Dr.  Wood  Jones  has  shown  that  the 
subclavian  groove  of  the  first  rib  is  caused  by 
the  lowest  trunk,  and  that  the .  pressure  of  this 
nerve  is  sufficient  to  cause  bending  of  the  rib  in 
some  cases.  It  is  not,  therefore,  surprising  that 
cases  are  recorded  of  nerve  disturbance  in  the 
distribution  of  the  lowest  trunk ^  in  individuals 
in  whom  there  is  no  cervical  rib.  The  lowest 
trunk  evidently  contains  the  main^  supply  of 
vaso-motor  nerves  to  the  limb,  for,  in  the  cases 
just  mentioned,  the  skin  is  often  red  and  swollen 
as  a  result  of  a  vaso-motor  paralysis. 

Paralysis  of  the  musculo-spiral  nerve.— When 
complete,  the  hand  is  flexed  and  hangs  flaccid 
("drop  wrist"),  and  neither  the  wrist  nor  the 
fingers  can  be  extended.  #  The  latter  are  bent 
and  cover  the  thumb,  which  is  also  flexed  and 
adducted.  When  attempts  are  made^  to  extend 
the  fingers,  the  interossei  and  lumbricales  alone 
act,  producing  extension  of  the  two  distal 
phalanges  and  flexion  of  the  proximal.  Supina- 
tion is  lost,  especially  if  the  elbow  be  extended 
so  as  to  exclude  the  action  of  the  biceps  muscle. 
Extension  at  the  elbow  is  lost,  but  there  is  practi- 
cally no  loss^  of  sensation  unless  the  nerve  is  cut 
above  the  origin  of  its  cutaneous  branches.  Sec- 
tion of  the  radial  nerve  in  the  upper  part  of 
the  forearm  gives  no  loss  of  sensation  (Head  and 
Sherren). 

Paralysis  of  the  median  nerve. — Flexion  of 
the  middle  phalanx  is  impossible  in  every  finger, 
as  is^  also  a  like  movement  of  the  distal  joint  of 
the  index  and  middle  fingers.  Partial  flexion 
of  the  distal  phalanges  of  the  two  inner  digits 
is  possible^  the  inner  part  of  the  flexor  pro- 
fundus being  supplied  by  the  ulnar  nerve. 
Flexion  of  the  proximal  phalanx  with  extension 
of  the  second  and  third  can  still  be  performed 
in  all  the  fingers  by  the  interossei.  The  thumb 
is  extended  and  adducted,  and  can  neither  be 
flexed  nor  opposed.  Bending  of  the  wrist  is  only 
possible  when  the  hand  is  forcibly  adducted  by 

L* 


330 


THE    UPPEIt    EXTREMITY 


[Chap. 


means  of  the  flexor  carpi  ulnaris,   which  is  not 
paralysed.     Pronation   is  lost. 

Section  of  the  median  or  ulnar  nerves  at 
the  wrist  does  not  give  rise  to  the  results  which 
one  would  expect  from  their  anatomical  dis- 
tribution. Such  lesions  have  been  recently  in- 
vestigated by  Head  and  Sherren.  After  section 
of  the  ulnar  nerve  in  the  forearm — taking  this 
nerve  as  an  example  to  explain  their  observations 
on  nerves  generally — they  found  that  a  certain  form 
of  sensibility,  which  they  name  epicritic,  is  lost 
over  the  area  of  anatomical  distribution  (Fig.  69). 


A  B  C  D 

Fig.  69. — Results  of  section  of  the  ulnar  nerve  (A,  B),  and 
of  the  median  nerve  (C,  D).     (Head  and  Sherren.) 

Black :  Area  in  which  epicritic  and  protopathic  sensibilities  are  lost. 
Stippled :  Area  in  which  only  epicritic  sensibility  is  lost. 

Over  this  area  the  patient  is  unable  to  distinguish 
light  touch  (tested  by  cotton-wool)  and  degrees 
of  temperature  between  22°-40°  C.  In  a  small 
area  of  the  fifth  digit  (see  Fig.  69)  neither  pricks 
nor  very  cold  or  very  hot  things  can  be  felt;  in 
this  area,  besides  epicritic  sensibility,  there  is  also 
lost  another  form  which  they  name  protopathic. 
But  every  where^  over  the  area  of  the  ulnar  nerve 
deep  pressure  is  felt;  deep  sensibility  remains 
because  the  nerves  which  subserve  it  arise  in  the 
forearm  and  reach  the  fingers  by  the  tendons. 
If  the  tendons  are  cut,  deep  sensibility  also  is 
lost.     The  effect  of  cutting  any  nerve  depends  on 


XV]  EPIPHYSES    OF    UPPER    LIMB  331 

the  nature  of  the  fibres  it  contains ;  a  nerve  may 
contain  epicritic  fibres  for  a  small  area  and  proto- 
pathic  for  a  much  wider,  or  vice  versa. 

Paralysis  of  the  ulnar  nerve, — Ulnar  flexion 
and  adduction  of  the  hand  are  limited.  Com- 
plete flexion  of  the  two  inner  fingers  is  impossible. 
The  little  finger  can  scarcely  be  moved  at  all. 
The  action  of  the  interossei  and  two  inner  lum- 
bricales  is  lost.  The  patient  is  unable  to  adduct 
the  thumb. 

In  testing  for  paralysis  of  muscles  in  the  hand 
it  is  extremely  important  to  observe  closely  the 
muscles  which  flex,  extend,  abduct,  and  adduct 
the  thumb.  The  ulnar  border  of  the  metacarpal 
of  the  thumb  can  be  approximated  to  the  radial 
border  of  the  corresponding  bone  of  the  index 
finger  by  only  two  muscles — the  adductor  pollicis 
and  first  dorsal  interosseous.  Theseare  paralysed 
when  the  ulnar  nerve  is  cut.  Their  action  may 
be  simulated  by  the  flexor  longus  pollicis,  brevi3 
pollicis,  or  opponens  pollicis,  but  in  such  cases  it 
will  be  observed  that  it  is  not  the  ulnar  border 
but  the  flexor  surface  of  the  thumb  which  is  moved 
towards  the  metacarpal  bone  of  the  index  finger. 

Epiphyses  of  the  upper  limb,— The  epi- 
physes about  the  elbow  join  the  shafts  of  their 
respective  bones  at  17  years  (except  the  tip  of  the 
internal  condyle,  which  joins  at  18).  The  epi- 
physes at  the  shoulder  and  wrist  extremities  of 
the  bones  join  at  20.  The  nutrient  canals  of  the 
three  bones  run  towards  the  elbow.  The  nutrient 
artery  of  the  humerus  comes  from  the  brachial 
or  inferior  profunda,  those  of  the  radius  and 
ulna  from  the  anterior  interosseous. 

The  nerve  supplying  the  humerus  is  the  mus- 
culocutaneous. The  radius  and  ulna  are  sup- 
plied by  the  anterior  interosseous  of  the  median. 
It  may  be  taken  as  a  general  law  that  the  nerve 
supply  of  a  bone  is  the  same  as  that  of  the  muscles 
which  are  attached  to  it. 


PART   IV.— THE   ABDOMEN    AND 
THE    PELVIS 

CHAPTER  XVI 
THE     ABDOMEN 

THE    ABDOMINAL    PARIETES 

Surface  anatomy. — The  degree  of  prominence 
of  the  abdomen  varies  greatly.  The  protuber- 
ance of  the  belly  in  young  children  is  mainly 
due  to  the  #  relatively  large  size  of  the  liver, 
which  occupies  a  considerable  part  of  the  cavity 
in  early  life.  It  also  depends  upon  the  small 
size  of  the  pelvis,  which ^  is  not  only  unable  to 
accommodate  any  abdominal  structure  (strictly 
so  called),  but  can  scarcely  provide  room  for 
the  pelvic  organs  themselves.  Thus  in  infancy 
the  bladder  and  a  great  part  of  the  rectum 
are  virtually  abdominal  viscera.  After  long- 
continued  distension,  as,  for  example,  after  preg- 
nancy, ascites,  etc.,  the  abdomen  usually  remains 
unduly  prominent  and  pendulous. 

In  cases  of  great  emaciation  it  becomes  much 
sunken,  and  its  anterior  wall  appears  to  have 
collapsed.  This  change  is  most  conspicuous  about 
the  upper  part  of  the  region.  Here  the  anterior 
parietes  immediately  below  the  line  of  the  costal 
cartilages,  instead  of  being  in  the  same  plane  with 
the  anterior  thoracic  wall,  may  so  sink  in  as  to 
332 


Chap.  XVI]    THE    ABDOMINAL    PARIETES  333 

be  almost  at  right  angles  with  that  wall  on  the 
one  hand,  and  with  the  lower  part  of  the  ab- 
dominal parietes  on  the  other.  In  such  cases  the 
abdominal  walls  just  below  the  thoracic  line  may 
appear  to  be  almost  vertical  when  the  patient  is 
in  the  recumbent  posture.  This  change  of  sur- 
face is  of  importance  in  gastrostomy,  since  the 
subjects  for  that  operation  are  usually  much 
emaciated,  and  the  incision  has  to  be  made  close 
below  the  costal  line. 

The  position  of  the  linea  alba  above  the  um- 
bilicus is  indicated  by  a  slight  median  groove, 
but  no  such  indication  exists  below  the  navel. 
The  linea  semilunaris  may  be  represented  by  a 
slightly  curved  line  drawn  from  about  the  tip  of 
the  ninth  costal  cartilage  to  the  pubic  spine. 
In  the  adult  it  would  be  placed  about  3  inches 
from  the  navel.  Above  the  umbilicus  the  line  is 
indicated  on  the  surface  by  a  shallow  depression. 
The  outline  of  the  rectus  can  be  well  seen  when  the 
muscle  is  in  action.  It  presents  three  "  linese 
transversa, ;;  one  usually  opposite  the  xiphoid 
cartilage,  one  opposite  the  umbilicus,  and  a  third 
between  the  two.  The  two  upper  of  these  lines 
are  obvious  in  well-developed  subjects. 

The  site  of  the  umbilicus  varies  with  the 
obesity  of  the  individual  and  the  laxity  of  the  ab- 
domen. It  is  always  below  the  centre  of  the  line 
between  the  xiphoid  cartilage  and  the  pubes.  In 
the  adult  it  is  some  way  above  the  centre  of  the 
body,  as  measured  from  head  to  foot,  while  in 
the  foetus  at  birth  it  is  below  that  point.  It  corre- 
sponds in  front  to  the  disc  between  the  third  and 
fourth  lumbar  vertebrae,  and  behind  to  the  tip  of 
the  third  lumbar  spinous  process.  It  is  situated 
about  j  of  an  inch  above  a  line  drawn  between  the 
highest  points  of  the  two  iliac  crests. 

The  anterior  superior  spine,  the  pubic  spine, 
and  Poupart's  ligament  are  all  conspicuous  and 
important  landmarks.  The  pubic  spine  is  nearly 
in  the  same  horizontal  line  as  the  upper  edge  of 
the  great  trochanter.     It  is  very  distinct  in  thin 


334         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

subjects.  In  the  obese  it  is  entirely  lost  beneath 
the  pubic  fat.  In  such  individuals,  however,  it 
can  be  detected,  when  the  subject  is  a  male,  by 
invaginating  the  scrotum  so  as  to  pass  the  finger 
beneath  the  subcutaneous  fat.  In  the  female  the 
position  of  the  process  may  be  made  out  by  ad- 
ducting  the  thigh  and  thus  making  prominent 
the  tendon  of  origin  of  the  adductor  longus  mus- 
cle. This  muscle  arises  from  the  body  of  the 
pubes  immediately  below  the  spine,  and  by  run- 
ning the  finger  along  the  muscle  the  bony  promi- 
nence may  be  reached.  If  the  finger  be  placed 
upon  the  pubic  spine  it  may  be  said  that  a  hernia 
descending  to  the  inner  side  of  the  finger  will  be 
inguinal,  while  one  presenting  to  the  outer  side 
will  be  femoral.  In  the  erect  position  of  the  body 
the  anterior  superior  spine  is  a  little  below  the 
level  of  the  promontory  of  the  sacrum,  while  a 
point  taken  over  the  junction  of  sternum  and 
ensiform  process — the  stemo-ensiform  point — is 
opposite  the  upper  part  of  the  tenth  dorsal  ver- 
tebra. This  point  can  be  readily  #  recognized  in 
even  fat  subjects  by  the  depression  below  the 
sternal  insertions  of  the  seventh  pair  of  costal 
cartilages,  and,  as  will  be  seen  presently,  forms 
a  valuable  landmark.  A  point  taken  midway 
between  the  umbilicus  and  sterno-ensiform — the 
mid-epigastric  point — lies  opposite  the  disc  be- 
tween the  first  and  second  lumbar  vertebrae  and 
is  a  j  surface-marking  of  great  clinical  utility 
(Addison). 

In  that  part  of  the  back  which  corresponds  to 
the  abdominal  region  the  erector  spinse  masses 
are  distinct,  and  in  any  but  fat  subjects  their 
outer  edges  can  be  well  defined.  Between  these 
masses  is  the  spinal  furrow,  which  ends  below  in 
an  angle  formed  by  the  two  great  gluteal  muscles. 
Immediately  behind  the  middle  of  the  crest  of  the 
ilium  is  Petit's  triangle,  or  the  gap  between  the 
external  oblique  and  latissimus  dorsi  muscles. 
The  fourth  lumbar  spine  is  about  on  a  level  with 
the  highest  part  of  the  iliac  crest.     In  counting 


XVI]  THE    ABDOMINAL    PAKIETES  335 

the  ribs  it  is  well  to  commence  from  above,  since 
the  last  rib  may  not  project  beyond  the  outer 
edge  of  the  erector  spinse,  and  may  consequently 
be  overlooked.  t 

The  aorta  bifurcates  opposite  the  middle  of  the 
body  of  the  fourth  lumbar  vertebra  just  to  the 
left  of  the  middle  line  about  f  of  an  inch  below 
and  to  the  left  of  the  umbilicus.  A  line  drawn 
on  either  side  from  the  point  of  bifurcation  to  the 
middle  of  Poupart's  ligament  will  correspond  to 
the  course  of  the  common  and  external  iliac 
arteries.  The  first  two  inches  of  this  line  would 
cover  the  common  iliac,  the  remainder  the  ex- 
ternal. 

The  coeliac  axis  comes  off  opposite  the  lower 
part  of  the  twelfth  dorsal  vertebra,  at  a  spot 
about  lj  inches  above  the  mid-epigastric  point, 
and  that  corresponds  behind  to  the  twelfth  dorsal 
spine.  The  superior  mesenteric  and  suprarenal 
arteries  are  just  below  the  axis.  The  renal  vessels 
arise  about  £  an  inch  below  the  superior  mesen- 
teric, opposite  the  mid-epigastric  point.  The  in- 
ferior mesenteric  artery  comes  off  from  the  aorta 
about  1  inch  above  the  umbilicus.  The  deep  epi- 
gastric artery  follows  a  line  drawn  from  the 
middle  of  Poupart's  ligament  to  the  umbilicus. 
Along  the  same  line  may  sometimes  be  seen  the 
superficial  epigastric  vein. 

The  abdominal  "  rings  "  will  be  referred  to 
under  Hernia  (p.  351). 

Anterior  Abdominal  Parietes 

The  skin  over  the  front  of  the  abdomen  is  loosely 
attached  in  the  region  of  the  groin.  It  is  more  adher- 
ent to  the  deeper  parts  in  the  middle  line  than  else- 
where, but  not  so  adherent  as  to  hinder  the  spread 
of  inflammation  from  one  side  of  the  abdomen  to 
the  other.  In  cases  of  great  obesity  two  transverse 
creases  form  across  the  belly,  one  crossing  the 
umbilicus  and  the  other  passing  just  above  the 
pubes.     In  the  former  of  the  two  creases  the  navel 


336         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

is  usually  hidden  from  sight.  In  cases  of  anky- 
losed  hip-joints  transverse  creases  are  often  noted 
running  across  the  middle  of  the  belly.  They  are 
produced  by  the  freer  bending  of  the  spine  that 
is  usually  required  in  ankylosis,  some  of  the 
simpler  movements  of  the  hip-joint  being  trans- 
ferred to  the  column  when  the  articulation  is 
rendered  useless. 

After  the  skin  has  been  stretched,  from  any 
gross  distension  of  the  abdomen,  certain  silvery 
streaks  appear  in  the  integument  over  its  lower 
part.  They  are  due  to  an  atrophy  of  the  skin 
produced  by  the  stretching,  and  their  position 
serves  to  indicate  the  parts  of  the  parietes  upon 
which  distending  forces  within  the  abdomen  act 
most  vigorously.  They  are  well  seen  after  preg- 
nancy, ascites,  ovarian  tumours,  etc. 

Beneath  the  skin  is  the  superficial  fascist, 
which  over  the  lower  half  of  the  abdomen  can  be 
readily  divided  into  two  layers.  The  great  bulk  of 
the  subcutaneous  fat  of  this  region  is  lodged  in  the 
more  superficial  of  the  two  layers.  In  cases  of 
great  obesity  the  accumulation  of  fat  is  perhaps 
more  marked  beneath  the  skin  of  the  abdomen 
than  it  is  elsewhere.  A  layer  of  fat  6  inches  in 
depth  has  been  found  in  this  region  in  cases  of 
great  corpulence.  The  superficial  vessels  and  nerves 
lie  for  the  most  part  between  the  two  layers  of  the 
fascia,  so  that  in  obese  subjects  incisions  may  be 
made  over  the  abdomen  to  the  depth  of  an  inch 
or  so  ^  without  encountering  blood-vessels  of  any 
magnitude. 

The  deep  layer  of  the  superficial  fascia  con- 
tains elastic  fibres,  and  corresponds  to  the  tunica 
abdominalis  or  "  abdominal  belt ;?  of  animals. 
It  is  attached  to  the  deeper  parts  along  the  middle 
line  as  far  as  the  symphysis,  and  to  the  fascia 
lata  just  beyond  Poupart's  ligament.  In  the  in- 
terval between  the  symphysis  and  the  pubic  spine 
it  has  no  attachment,  but  passes  down  into  the 
scrotum  and  becomes  the  dartos  tissue.  Extrava- 
sated   urine   that  has   reached   the   scrotum   may 


XVIJ       ANTERIOR    ABDOMINAL    TARIETES         337 

mount  up  on  to  the  abdomen  through  this  in- 
terval, and  will  then  be  limited  by  the  deeper 
layer  of  the  fascia.  It  will  not  be  able  to  pass 
;  down  into  the  thigh  on  account  of  the  attachments 
i  of  the  fascia,  nor,  for  a  like  reason,  will  it  tend 
to  pass  over  the  middle  line.  In  the  same  way 
emphysematous  collections  following  injuries  to 
the  chest,  when  beneath  the  deeper  layer  of  the 
fascia,  receive  a  check  at  the  groin,  and  lipomata 
also  that  grow  beneath  the  membrane  tend  to  be 
limited  by  the  middle  line  and  that  of  Poupart's 
ligament. 

The  anterior  abdominal  parietes  vary  in  thick- 
ness in  different  subjects.  In  cases  of  great 
emaciation  the  outlines  of  some  of  the  viscera  may 
be  readily  made  out  or  even  seen  through  the 
thinned  wall.  In  some  cases  of  chronic  intestinal 
obstruction  the  outlines  of  the  distended  intestine 
are  visible,  and  their  movements  can  be  watched ; 
in  instances  of  obstruction  of  the  pylorus  the 
movements  of  the  dilated  and  hypertrophied 
stomach  can  often  be  seen.  The  relative  thickness 
of  the  abdominal  wall  in  various  subjects  depends 
rather  upon  the  amount  of  the  subcutaneous  fat 
than  upon  the  thickness  of  the  muscles.  This 
muscular  boundary  affords  an  admirable  protec- 
tion to  the  viscera  within.  By  contracting  the 
abdominal  muscles  the  front  of  the  belly  can  be 
made  as  hard  as  a  board,  and  in  acute  peritonitis 
this  contraction  can  sometimes  be  seen  to  produce 
a  remarkable  degree  of  rigidity. 

A  blow  upon  the  abdomen  when  the  muscles 
are  firmly  contracted  will  probably  do  no  injury 
to  the  viscera  unless  the  violence  be  extreme.  The 
rigid  muscular  wall  acts  with  the  efficacy  of  a 
dense  indiarubber  plate.  It  may  be  bruised  or 
torn,  but  it  will  itself  receive  the  main  shock  of 
the  contusion. 

The  probable  effect  on  the  contained  viscera 
of  a  blow  upon  the  abdomen  will  depend  upon 
many  factors;  but,  so  far  as  the  walls  themselves 
are   concerned,    the   effect  greatly   depends   upon 


338         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

whether  the  blow  was  anticipated  or  not,  and 
upon  the  extent  of  the  padding  of  fat  that  is  fur- 
nished to  the  parietes.  If  the  blow  be  anticipated 
the  muscles  of  the  belly  will  be  instinctively 
contracted,  and  the  viscera  at  once  provided 
with  a  firm  but  elastic  shield.  Thus  the  abdo- 
minal muscles  have  been  found  bruised  and  torn 
while  the  viscera  were  intact,  and,  on  the  other 
hand,  in  cases  probably  where  the  muscles  were 
inert  or  taken  unawares,  a  viscus  has  been  found 
to  be  damaged  without  there  being  any  con- 
spicuous lesion  in  the  belly  wall.  If  the  blow  be 
anticipated  also  the  body  will  probably  be  abruptly 
bent  and  the  viscera  be — as  it  were — removed  from 
danger. 

Along  the  linea  alba  the  abdominal  wall  is 
thin,  dense,  and  free  from  visible  blood-vessels. 
Hence  in  many  operations  upon  the  abdominal 
cavity  the  incision  is  made  in  the  middle  line. 
Along  the  outer  border  of  the  rectus  muscle  (i.e. 
about  and  just  beyond  the  linea  semilunaris)  the 
parietes  are  also  thin  and  lacking  in  vessels,  and 
consequently  that  situation  is  well  suited  for 
an  incision.  Except  in  some  operations  on  the 
kidney,  stomach,  or  gall-bladder,  incisions  are 
seldom  so  placed.  In  most  cases  it  is  a  question 
of  either  opening  the  abdomen  in  the  middle  line 
or  in  one  of  the  iliac  regions.  About  1  inch 
below  the  navel  the  two  recti  muscles  are  almost  in 
contact,  and  here  the  linea  alba  can  scarcely  be 
said  to  exist,  while  above,  the  muscles  remain 
apart,  the  linea  alba  being  normally  §  of  an  inch 
wide.  In  pregnancy,  obesity,  and  ascites  the  supra- 
umbilical  part  may  become  2  or  more  inches  wide, 
but  the  narrow  infra-umbilical  part  is  unaffected ; 
when  this  part  of  the  linea  alba  widens  the  con- 
dition is  known  as  divarication  of  the  recti. 
When  this  is  the  case  the  contents  of  the  abdomen 
bulge  out  between  the  recti  when  these  two  muscles 
are  thrown  into  action,  as  when  a  patient  at- 
tempts to  assume  the  sitting  from  a  supine 
posture    unaided   by    the    arms.     Pellets    of    sub- 


XVI]  THE    UMBILICUS  339 

j  peritoneal  fat  may  grow  through  interstices  in 
the  linea  alba  and  give  rise  to  what  are  called 
"  fatty  hernise." 

The  fibrous  ring  of  the  umbilicus  is  derived 
from  the  linea  alba.  To  this  ring  the  adjacent 
structures — skin,  fascia,  and  peritoneum — are  all 
closely  adherent.  The  adhesion  is  such,  and  the 
amount  of  tissue  between  the  skin  and  peritoneum 
is  so  scanty,  that  in  operating  upon  an  umbilical 
hernia  it  is  scarcely  possible  to  avoid  opening  the 
sac. 

The  umbilicus  represents  the  point  where  the 
lateral  abdominal  walls  finally  close.  At  the 
sixth  week  the  opening  is  funnel-shaped  and  con- 
tains the  yolk  sac  and  a  fold  of  the  bowel  to  which 
it  is  attached.  This  condition  may  persist  and 
give  rise  to  a  congenital  umbilical  hernia.  In 
the   foetus  three  vessels  enter   at  the   navel,    and 

i  immediately  separate  on  reaching  the  abdominal 
cavity,  the  vein  passing  directly  upwards  and  the 

|  arteries  obliquely  downwards.  Running  down 
from  the  umbilicus  in  the  middle  line  is  also  the 

I  remains  of  the  urachus.  In  the  foetus,  the  spot 
where  the  three  vessels  part  company  is  about  the 
centre  of  the  navel,  and  it  thus  happens  that  in  a 
congenital  umbilical  hernia  the  gut  as  it  escapes 
separates  the  three  vessels,  which  become  to  some 
extent  spread  over  it.  The  congenital  hernia,  in- 
deed, works  its  way  in  among  the  structures  of 
the  cord  and  receives  its  main  coverings  from 
them.  These  hernise  are  fortunately  rare,  for  in 
certain  instances  they  extend  some  way  into  the 
cord,  and  in  at  least  two  reported  cases  the  gut 
was  cut  across  by  the  accoucheur  in  dividing  the 
cord  at  birth.*  As  the  abdomen  increases  in 
height  the  contraction  of  the  two  obliterated 
arteries  and  of  the  urachus  drags  upon  the  cica- 
trix   and    pulls    it    backwards    and    downwards. 

*  The  congenital  hernia  must  be  distinguished  from  the  infantile 
umbilical  hernia  so  commonly  met  with  after  separation  of  the  cord.  For 
an  account  of  these  congenital  hernise,  see  paper  by  the  Author  in  the 
Lancet,  vol.  i.,  1881,  p.  323. 


340         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

Thus,  in  the  adult  umbilical  ring,  as  viewed  from 
the  inner  side,  the  cords  representing  not  only  the 
obliterated  arteries  and  the  urachus,  but  also  the 
vein,  appear  to  start  from  the  lower  border  of 
the  cicatrix.  In  adult  herniae,  indeed,  the  gut 
escapes  above  both  the  obliterated  arteries  and 
the  vein.  The  upper  half  of  the  cicatrix  is  thin 
when  compared  to  the  lower  half,  and  is  sup- 
ported also  by  less  firm  adhesions. 

In  some  cases  there  is#  found  at  the  navel  a 
fistula  that  discharges  urine.  This  is  due  to  a 
patent  urachus.  The  urinary  bladder  is  formed  by 
a  dilatation  of  the  stalk  of  the  allantois.  The  part 
below  this  dilatation  becomes  the  first  part  of 
the  urethra,  that  above  becomes  the  urachus.  In 
one  instance  of  patent  urachus  the  abnormal  open- 
ing was  1  inch  in  diameter.  The  patient,  a  man 
aged  40,  had  a  stone,  which  was  extracted  by 
passing  the  finger  into  the  bladder  through  the 
opening  at  the  umbilicus. 

Sometimes  a  fistula  discharging  faeces  is  met 
with  at  the  navel.  This  depends  upon  the  per- 
sistence of  the  vitello-intestinal  duct,  a  duct  that 
at  one  time  connects  the  intestine  of  the  early 
foetus  with  the  yolk  sac,  and  which  generally  dis- 
appears without  leaving  any  trace.  The  per- 
sistent duct,  when  it  occurs,  is  known  as  Meckel's 
diverticulum,  and  springs  from  the  ileum  some 
two  or  more  feet  above  the  ileo-caecal  orifice. 
This  foetal  relationship  also  explains  the  presence 
of  a  fibrous  cord  which  is  sometimes  seen  con- 
necting Meckel's  diverticulum  with  the  umbilicus. 
This  fibrous  cord  may  cause  strangulation  of  the 
bowel  (Fig.   79,   p.   393). 

The  position  of  the  transverse  intersections  of 
the  rectus  muscle  should  be  borne  in  mind. 
They  adhere  to  the  anterior  layer  of  the  rectus 
sheath,  but  not  to  the  posterior.  They  are  able, 
therefore,  to  some  extent  to  limit  suppurative 
collections  and  haemorrhages  beneath^  the  sheath 
on  its  anterior  aspect.  This  muscle  is  often  the 
seat  of  one  form  of  "  phantom  tumour."     These 


XVII  THE    KECTTJS  341 

tumours  are  mostly  met  with  in  the  hysterical 
and  hypochondriac,  and  when  associated  with 
some  vague  abdominal  symptoms  are  apt  to  mis- 
lead. They  are  due  to  a  partial  contraction  of 
the  muscle,  usually  to  a  part  between  two  inter- 
sections, and  are  said  to  be  more  common  in  the 
upper  part  of  the  rectus.  When  the  fibres  of  the 
muscle  are  contracted  the  "  tumour  "  is  obvious, 
but  when  they  relax  it  disappears.  The  phantom 
tumour,  however,  is  not  always  a  matter  of  little 
moment.  It  may  be  associated  with  grave  disease 
within  the  abdomen,  and  be  due  to  reflex  muscular 
contraction,  the  starting  point  of  such  reflex  act 
being  in  the  viscera.  These  localized  contractions 
may  provide  a  clue  to  the  seat  of  visceral  disease. 
Thus  the  stomach  derives  its  chief  sensory  nerve 
supply  from  the  eighth  dorsal  segment  of  the 
cord;  the  section  of  the  rectus  between  the  upper 
and  middle  inscriptions  is  also  supplied  from 
this  segment  through  the  eighth  dorsal  nerve ; 
hence  contraction  of  this  section  may  be  asso- 
ciated with  disease  of  the  stomach.  The  rectus 
receives  nerves  from  the  lower  six  dorsal  nerves; 
the  section  at  the  umbilicus  is  supplied  by  the 
tenth. 

I  have,  for  example,  seen  a  conspicuous  phan- 
tom tumour  in  the  upper  part  of  the  right  rectus 
associated  with  cancer  of  the  stomach,  with  ulcer 
of  the  duodenum,  and  with  malignant  disease  of 
the  peritoneum. 

Other  vanishing  tumours  depend  upon  disten- 
sion of  the  intestines  by  flatus  or  by  faecal 
matter.  In  great  distension  of  the  abdomen  the 
fibres  of  the  rectus  may  be  much  stretched,  since 
they  bear  the  brunt  of  the  distending  force. 
The  direction  of  the^  fibres  also  renders  them 
liable  to  be  torn  in  opisthotonos,  or  extreme  arch- 
ing of  the  back,  or  tetanus.  Portions  of  the  muscle 
have  also  been  ruptured  by  muscular  violence,  as 
in  vaulting. 

The  lateral  muscles  of  the  front  abdominal 
wall   are  separated   from   one   another   by   layers 


342         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

of  loose  connective  tissue.  In  the  tissue  between 
the  internal  oblique  and  transversalis  are  found 
the  chief  nerves  and  arteries. 

Everywhere  the  peritoneum  is  bound  to  the 
abdominal  wall  by  subperitoneal  connective 
tissue.  In  the  pelvis  this  tissue  is  lax  to  allow 
the  viscera  of  the  pelvis — the  bladder,  rectum, 
and  uterus — to  expand;  so,  too,  over  the  iliac 
fossae  and  on  the  anterior  abdominal  wall  for 
two  inches  above  Poupart's  ligament  and  the 
symphysis  pubis;  but  above  this  level  and  on 
the  under  surface  of  the  diaphragm  it  binds  the 

f>eritoneum  down  closely.  The  looseness  of  this 
ayer  greatly  favours  the  spread  of  abscess,  to 
the  progress  of  which  it  offers  little  resistance. 
Such  an  abscess  may  spread  from  the  viscera, 
especially  from  those  that  have  an  imperfect 
peritoneal  covering,  as,  for  example,  the  kidney, 
the  vertical  parts  of  the  colon,  etc.  The  laxity 
of  this  tissue  has  been  of  service  in  certain 
surgical  procedures.  Thus  the  external  and 
common  iliac  arteries  can  be  reached  by  an  in- 
cision made  some  way  to  the  outer  side  of  the 
vessels  and  without  opening  the  peritoneum. 
That  membrane  having  been  exposed  in  the 
lateral  wound,  the  artery  is  reached  by  working 
a  way  with  the  finger  through  the  subperitoneal 
tissue,  and  by  actually  stripping  the  serous  mem- 
brane from  its  attachments.  Ligature  of  the 
iliac  vessels  at  the#  present  day  is  usually  effected 
through  a  direct  incision  which  opens  the  peri- 
toneal cavity.  The  method  just  detailed  belongs 
to  pre-antiseptic  days.  The  laxity  of  the  sub- 
serous layer  also  favours  that  stretching  of  the 
peritoneum  which  occurs  under  certain  circum- 
stances. 

Wounds  of  the  abdomen  may  give  trouble 
in  their  treatment,  since,  when  inflicted,  they 
may  open  up  several  layers  of  fascia  and  so  lead 
to  bagging  of  pus  and  to  the  spread  of  suppura- 
tion should  an  abscess  follow  the  lesion.  The 
constant  respiratory  movements  of  the  belly  walls 


XVI]        VESSELS    OF    ABDOMINAL    WALLS  343 

do  not  favour  that  rest  which  is  so  essential  to 
the  healing  of  wounds.  In  penetrating  wounds 
the  contraction  of  the  muscles  may  encourage  the 
protrusion  of  the  viscera,  especially  when  the 
incision  is  transverse  to  the  direction  of  the 
muscular  fibres.  In  reducing  small  portions  of 
protruded  viscera  it  is  quite  possible  to  push 
them  into  one  of  the  connective  tissue  spaces  be- 
tween the  muscles  or  into  the  subserous  tissue  in- 
stead of  into  the  peritoneal  cavity.  In  applying 
sutures  to  wounds  involving  the  whole  thickness 
of  the  parietes  it  is  necessary  that  the  threads 
should  include  the  peritoneum,  so  that  early 
healing  of  that  membrane  may  be  brought  about. 
Without  such  precaution  a  gap  may  be  left 
in  the  surface  of  the  peritoneum  which  would 
favour  the  formation  of  a  hernia  in  the  site  of 
the  old  wound. 

Blood-vessels.— The  only  arteries  of  any  mag- 
nitude in  the  abdominal  walls  are  the  two 
epigastric  arteries,  some  branches  of  the  deep 
circumflex  iliac,  the  last  two  intercostal  vessels, 
the  epigastric  branch  of  the  internal  mammary, 
and  the  abdominal  divisions  of  the  lumbar 
arteries.  The  superficial  vessels  are  of  small 
size,  although  Verneuil  reports  a  case  of  fatal 
haemorrhage  from  the  superficial  epigastric 
vessel. 

The  superficial  veins  on  the  front  of  the 
abdomen  are  numerous,  and  are  very  distinct 
when  varicose.  A  lateral  vein,  extending  from 
the  axilla  to  the  groin,  uniting  the  axillary  and 
femoral  veins,  is  often  rendered  in  this  way  very 
prominent.  The  surface  abdominal  veins  may 
take  no  part  as  alternative  blood  channels  in 
cases  of  obstruction  of  the  inferior  vena  cava. 
Clinical  experience  shows  that  these  veins  may 
be  also  enormously  varicose  in  instances  where 
the  inferior  cava  is  quite  patent.  In  one  case 
under  my  care  there  was  extensive  varicosity  of 
the  surface  veins  from  the  pectoral  region  to  the 
groin  that  involved  one  side  of  the  body  only. 


344         THE    ABDOMEN    AND    THE    PELYIS     [Chap. 

It  has  been  shown,  moreover,  that  the  valyes  of 
these  vessels  are  so  arranged  that  the  blood  in  the 
surface  veins  above  the  navel  goes  to  the  axilla, 
while  that  in  the  veins  of  the  subumbilical  region 
runs  to  the  groin.  In  the  neighbourhood  of  the 
umbilicus  these  veins  are  connected  with  the 
portal  vein  in  the  liver  through  anastomotic 
venous  channels  in  the  falciform  ligament  of  the 
liver  (Sappey). 

As  regards  the  surface  lymphatics  of  the 
front  of  the  abdomen,  it  may  be ( said  in  general 
terms  that  those  above  the  umbilicus  go  to  the 
axillary  glands,  and  those  below  to  the  glands 
of  the  groin. 

Nerves.  — -  The  abdominal  wall  is  supplied  by 
the  lowest  six  dorsal  or  intercostal  nerves,  and 
by  the  first  lumbar  nerve.  These  nerves  run 
obliquely  to  the  long  axis  of  the  abdomen  down- 
wards and  inwards  from  the  sides  to  the#  middle 
line  and  hence  are  damaged  more  extensively  in 
vertical  than  in  oblique  incisions.  Their  direc- 
tion is  represented  by  a  continuation  of  the  lines 
of  the  ribs  :  they  are  placed  parallel  to  one 
another  and  at  fairly  equal  distances  apart.  It 
is  important  to  note  that  they  supply  not  only 
the  abdominal  integument,  but  also  the  muscles 
of  the  belly,  viz.  the  rectus,  the  two  oblique 
muscles,  and  the  transversalis.  The  segments  of 
the  spinal  cord  which  supply  the  skin#  also 
innervate  the  underlying  muscles,  an  association 
of  great  importance  (Fig.  70).  If  a  cold  hand 
be  suddenly  placed  upon  the  belly  the #  muscles 
at  once  contract  and  the  abdomen  is  instinctively 
rendered  rigid.  The#  safety  of  the  viscera,  at 
least  so  far  as  protection  from  contusions  is  con- 
cerned, depends  upon  the  readiness  with  which 
the  muscles  can  contract  at  the  first  indication 
of  danger.  As  has  been  already  stated,  the 
viscera  have  a  very  efficient  protection  against 
the  effects  of  blows  when  the  belly  muscles  are  in 
a  state  of  rigid  contraction.  The  sensitive  skin 
acts  the  part  of  a  sentinel,  and  the  intimate  asso- 


XVI] 


NERVES    OF    ABDOMINAL    WALLS 


345 


ciation  of  the  surface  nerves  with  the  muscular 
nerves  allows  the  warnings  of  this  sentinel  to  be 
readily  given  and  immediately  acted  upon.  The 
rigidity  of  the  muscles  in  certain  painful  affec- 
tions of  the  skin  over  the  abdomen  is  often  very 


DlAPHRAQMATlC 

Cardiac 
Oesophageal 


esical 
emalTesticular 


Fig.  70. — Showing  approximately  the  areas  of  skin  supplied 
tby  spinal  nerves  on  the  anterior  surface  of  the  trunk. 

The  areas  are  marked  on  the  left  side  by  dotted  lines,  and  the  number 
of  the  spinal  nerve  by  which  each  is  supplied  is  indicated.  The 
nerves  are  shown  on  the  right  side.  The  red  stippled  areas  show 
the  regions  to  which  pain  is  commonly  referred  in  connexion 
with  visceral  disease— according  to  the  observations  of  Dr.  James 
Mackenzie.  The  pain  radiates  towards  the  unenclosed  part  of 
each  area. 

conspicuous.  I  might  instance  the^  case  of  a 
man  with  a  burn  over  the  belly.  While  the  burn 
is  protected  by  the  dressings  the  abdominal 
muscles  are  lax  and  the  parietes  move  with  the 
respiratory  act.  The  moment  the  dressings  are 
removed,  the  surface  becoming  painful,  its  spinal 


346         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

centre  becomes  excited  and  the  muscles  at  once 
contract  and  the  belly  becomes  rigid. 

It  will  be  noticed  that  six  of  the  abdominal 
nerves  supply  intercostal  muscles,  and  are  thus 
intimately  associated  with  the  movements  of  re- 
spiration. The  abdominal  muscles  are  of  course 
concerned  "in  the  same  movements.  These  asso- 
ciations are  illustrated  when  cold  water  is  sud- 
denly dashed  upon  the  belly.  The  subject  of 
such  experiment  at  once  experiences  a  violent 
respiratory  movement  in  the  form  of  a  deep 
gasp.  When  the  abdominal  muscles  are  firmly 
fixed  the  lower  ribs  are  also  rigid,  and  respiration 
is  limited  to  the  higher  ribs  and  to  the  thorax 
proper. 

There  are  other  practical  points  about  these 
nerves.  In  caries  of  the  spine,  and  in  certain 
injuries  to  the  column,  the  spinal  nerves  may 
suffer  injury  as  they  issue  from  the  vertebral 
canal.  This  injury  may  show  itself  by  modified 
sensation  in  the  parts  supplied  by  such  nerves. 
Thus  in  Pott's  disease  the  patient  often  com- 
plains of  a  sense  of  tightness  about  the  abdomen, 
as  if  a  cord  were  tied  around  it.  This  sense^  of 
constriction  depends  upon  an  impaired  sensation 
in  the  parts  supplied  by  a  certain  pair  of  nerves ; 
or,  if  the  sense  of  constriction  be  wider  spread, 
by  two  or  more  pairs  of  nerves.  In  other  cases 
a  sense  of  pain  may  take  the  place  of  that  of 
constriction.  It  would  hardly  be  believed  that 
spinal  disease  has  been  mistaken  for  "  belly- 
ache.';  But  many  such  cases  have  been  recorded. 
A  child  complains  of  pain  over  the  pit  of  the 
stomach  or  about  the  umbilicus,  and  this  feature 
may  quite  absorb  for  a  while  the  surgeon's  atten- 
tion. The  abdomen  is  carefully  poulticed,  while 
the  only  mischief  is  in  the  vertebral  column. 
Other  symptoms,  however,  develop,  and  it  be- 
comes evident  that  the  pain  is  due  m  to  pressure 
upon  the  nerves  supplying  the  skin  over  the 
epigastric  or  umbilical  regions,  and  that  that 
pressure  is  a  circumstance  in  the  course  of  spinal 


XVI]         NEEVES    OF    ABDOMINAL    WALLS  347 

bone  disease.  A  case  came  under  my  notice  in 
which  a  man  complained  of  intense  and  abiding 
pain  over  the  stomach.  The  pain  was  made 
worse  by  food,  and  as  all  means  used  failed  to 
relieve  it,  the  abdomen  was  opened  by  an  ex- 
ploratory incision.  Nothing  abnormal  was  dis- 
covered. A  little  later  it  became  evident  that 
the  pain  was  due  to  a  malignant  tumour  situated 
in  the  bodies  of  the  dorsal  vertebrae.  There  had 
never,  before  the  operation,  been  any  suspicion 
of  spinal  disease.  The  site  of  the  painful  part 
depends,  of  course,  upon  the  position  of  the 
spinal  ailment,  and  thus  the  cutaneous  symptoms 
may  serve  to  localize  the  caries  in  the  vertebrae. 
Thus  the  skin  over  the  "  pit  of  the  stomach  "  is 
supplied  by  the  sixth  and  seventh  dorsal  nerves, 
and  the  tenth  nerve  is  nearly  in  a  line  with  the 
umbilicus.  The  position  of  the  areas  supplied 
by  each  spinal  nerve  on  the  trunk  is  shown  in 
Fig.  70.  The  umbilicus  may  be  at  the  upper  or 
lower  border  of  the  area  of  the  tenth,  accord- 
ing to  the  individual.  A  spinal  root  may  be 
cut  and  yet  scarcely  a  trace  of  anaesthesia  may 
result  owing  to  the  overlapping  of  the  nerve 
distributions. 

Not  only  may  a  lesion  at  the  origin  of  a  spinal 
nerve  give  rise  to  a  pain  referred  by  the  patient 
to  the  abdomen,  but,  as  may  be  readily  understood 
from  the  .fact  that  the  nerves  of  the  abdominal 
wall  also  supply  the  lower  half  of  the  thorax, 
thoracic  lesions  may  also  give  rise  to  symptoms 
which  are  referred  to  the  abdomen.  Pain  or  tender 
areas  in  the  upper  part  of  the  abdomen  may  be 
actually  due  to  a  pleurisy  in  the  lower  part  of 
the  thorax. 

Although  the  course  of  the  spinal  nerves  in 
the  body  wall  is  oblique — following  the  axes  of 
the  ribs — yet  in  their  final  distribution  they  supply 
zones  of  skin  which  approximately  pass  horizont- 
ally round  the  body.  This  is  due  to  the  fact 
that  the  posterior  primary  divisions  and  lateral 
cutaneous  branches,  before  they  reach  their  areas 


348         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

of  skin,  descend  to  the  same  level  as  the  anterior 
cutaneous  nerves — the  terminal  branches  of  the 
anterior  divisions.  Indeed,  the  lateral  cutaneous 
nerves  of  the  lower  segments,  as  the  lower  limb 
is  approached,  actually  descend  further  than  the 
anterior  cutaneous  nerves  (Fig.  70).  The  hori- 
zontal arrangement  of  the  skin  areas  is  demon- 
strated by  the  distribution  of  the  cutaneous 
lesions  in  herpes  zoster — a  disease  which  is  now 
ascribed  to  a  lesion  of  the  ganglia  of  the  pos- 
terior roots. 

The  nerves  of  the  body  wall  have  still  more 
important  associations.  The  cord  segments  with 
which  they  are  connected  are  also  in  communica- 
tion with  the  viscera  of  the  abdomen  and  thorax 
through  the  sympathetic  system.  Hence  diseased 
conditions  in  the  abdominal  viscera  give  rise  to 
disturbances  in  the  corresponding  cord  segments, 
and  the  brain,  being  accustomed  to  localize  pain 
only  along  the  spinal  nerves,  makes  a  mistake  and 
refers  the  pain  along  the  spinal  nerve  of  the  seg- 
ment disturbed.  Not  only  is  pain  referred,  but 
the  skin  supplied  from  the  disturbed  spinal  seg- 
ments becomes  tender,  and  through  a  study  of 
these  areas  of  tenderness  Head  has  been  able  to 
localize  the  visceral  centres  in  the  spinal  cord, 
thus  affording  the  surgeon  a  means  for  increased 
accuracy  of  diagnosis.  The  abdominal  viscera 
are  supplied  from  the  sixth  dorsal  to  the  first 
lumbar  spinal  segments,  the  nerves  t  passing  to 
their  destinations  through  the  rami  communi- 
cantes,  splanchnic  nerves  and  sympathetic 
plexuses  of  the  abdomen.  No  visceral  nerves  es- 
cape by  the  second,  third,  or  fourth  lumbar 
nerve  roots,  hence  these  are  never  the  seats  of 
visceral  referred  pains.  The  pelvic  viscera  are 
supplied  from  the  fifth  lumbar  to  the  third  or 
sometimes  fourth  sacral  nerve  through  the  nervi 
erigentes. 

It  is  important  to  remember,  too,  that  there 
are  three  systems  of  nerves  in  the  belly  wall  : 
(1)  the  nerves  to  the  skin;   (2)  the  nerves  to  the 


XVI]         NERVES    OF    ABDOMINAL    WALLS  349 

muscles  (motor  and  sensory) ;  (3)  the  nerves  to  the 
parietal  peritoneum.  Any  one  or  all  of  these  three 
sets  may  be  the  seat  of  referred  pain,  the  most 
common  being  the  muscular  nerves.  The  pain 
elicited  by  pressure  on  the  muscles  or  by  move- 
ments is  usually,  but  erroneously,  regarded  as 
situated  in  the  diseased  viscus.  The  tonus  and 
condition  of  the  muscles  of  the  abdominal  pari- 
etes  are  influenced  by  the  condition  of  the  vis- 
cera through  the  >  interconnexion  of  their  nerve 
systems  in  the  spinal  cord. 

The  following  are  the  segments  with  which 
each  viscus  is  connected  (Head)  :  Stomach,  6,  7, 
8,  9  D. ;  intestine,  9,  10,  11,  12  D. ;  rectum,  2,  3, 

4  S.  ;  liver  and  gall  bladder,  7,  8,  9,  10  D.  ;  kidney 
and  ureter,  10,  11,  12  D.,  1  L. ;  prostate,  10,  11  D., 

5  L.,  1,  2,  3  S.  ;  epididymis,  11,  12  D.,  1  L. ;  testis 
and  ovary,  10  D. ;  appendages  of  uterus,  11,  12  D., 
1  L.  ;  uterus,  10,  11,  12  D.,  1  L.,  3,  4  S. 

This  nerve  relationship  is  illustrated  in  dis- 
ease in  many  ways.  Thus,  in  acute  peritonitis 
and  in  laceration  of  certain  of  the  viscera  the 
abdominal  muscles  become  rigidly  contracted,  so 
as  to  insure  as  complete  res£  as  possible  to  the 
injured  parts.  In  acute  peritonitis,  again,  the 
belly  is  very^  hard,  and  the  respirations  are 
purely  thoracic ;  and  so  entirely  do  the  cuta- 
neous ^  portions  of  these  nerves  _  enter  into  the 
situation,  that  the  patient  is  frequently  unable 
to  tolerate  even  the  most  trifling  pressure  upon 
his  abdomen. 

Congenital  deformities  of  the  abdomen.  — 
At  the  end  of  the  second^  month  of  development, 
part  of  the  intestine  projects  through  the  widely 
open  umbilicus  within  the  cord  when  it  is  only 
covered  by  the  transparent  covering  membrane  of 
that  structure.  In  the  third  month  the  intestines 
retreat  within  the  abdomen,  the  cavity  within  the 
cord  becoming  obliterated  and  the  umbilicus 
closed.  e  The  process  of  retraction  of  the  intestine 
may  fail  or  even  an  opposite  process  may  occur — 
other    contents    being    added    to    those    normally 


350 


THE    ABDOMEN    AND    THE    PELVIS    [Chap. 


found  within  the  cord.  Thus  result  the  various 
forms  of  congenital  exomphalos,  which  may  vary 
in  severity  from  a  small  hernia  to  a  protrusion 
of  the  whole  of  the  more  movable  viscera.  One  of 
the  most  remarkable  deformities  is  that  known  as 
extroversion  of  the  bladder  (ectopia  vesicae).  Here, 
not  only  is  a  part  of  the  belly  wall  apparently 
absent,   but    also    a    part    of    the    genito-urinary 


Membrane  of  Bladder 


W^    VuC 


Fr-cnum 
Fig.  71. — Condition  of  parts  in  extroversion  of  the  bladder 

apparatus.  In  complete  cases  there  is  a  defect 
in  the  abdominal  wall  from  the  umbilicus  to 
the  urethra.  There  is  a  widely  open  or  defective 
symphysis  pubis,  and  the  anterior  wall  of  the 
bladder,  the  principal  part  of  the  penis,  and 
the  whole  of  the  roof  of  the  urethra  are  absent 
(Fig.  71).  The  interior  of  the  bladder  and  urethra 
are  laid  open  and  form  part  of  the  anterior 
abdominal  wall.     The  unprotected  or  vesical  area 


XVI]  INGUINAL    HERNIA  351 

offers  a  weak  resistance  to  the  descent  of  the 
viscera,  and  bulges  outwards  when  the  patient 
stands  up.  The  scrotum,  also,  as  might  be  ex- 
pected from  a  reference  to  the  development  of 
that  part,   is  bifid. 

HERNIA 

1.  Inguinal  hernia. — In  this  form  of  rup- 
ture the  herniated  bowel  occupies  the  inguinal 
canal  for  the  whole  or  part  of  its  entire  length. 
This  canal  runs  obliquely  from  the  internal  to 
the  external  abdominal  ring,  and  is  about  li 
inches  in  length.  It  represents  the  track  followed 
by  the  testis^  in  its  descent.  It  is,  in  a  sense, 
a  passage  right  through  the  abdominal  wall, 
and  is  occupied  by  the  spermatic  cord.  It  is 
not  a  free  canal,  however,  in  the  same  sense  as 
one  would  speak  of  an  open  tube,  but  is  rather  a 
potential  one,  a  tract  of  tissue  so  arranged  as  to 
permit  of  a  body  being  thrust  along  it.  It  is  a 
breach  in  the  abdominal  wall,  not  a  doorway ; 
a  breach  that  is  forcibly  opened  up  and  widened 
in  the  acquired  forms  of  hernia.  When  a  hernia 
occupies  the  inguinal  canal  it  is  covered  in 
front  by  the  integuments,  the  external  oblique 
aponeurosis,  and  the  lower  fibres  of  the  inter- 
nal oblique  and  transversalis  muscles.  It  rests 
behind  upon  the  transversalis  fascia,  the  con- 
joined tendon,  and  the  triangular  fascia ;  over 
it  arch  the  transverse  and  internal  oblique 
muscles,  while  below  it  is  the  angle  formed  by 
the  union  of  ^Poupart's  ligament  with  the  trans- 
versalis fascia.  The  herniated  bowel  is  con- 
tained within  a  "  sac/'  which  is  always  formed 
of  peritoneum.  In  congenital  hernia  the  sac 
exists  already  formed  as  an  abnormally  patent 
"  processus  vaginalis."  In  acquired  hernise  the 
sac  consists  of  that  part  of  the  parietal  peri- 
toneum which  the  gut  pushes  before  it  in  its 
descent. 

The  ^external  abdominal  ring,  J  an  inch  ex- 
ternal to  and  above  the  pubic  spine,   is  readily 


352 


THE    ABDOMEN    AND    THE    PELVIS    [Chap. 


felt  by  invaginating  the  scrotum  with  the  point 
of  the  finger,  and  then  passing  the  digit  up  in 
front  of  the  cord.  If  the  nail  be  kept  against  the 
cord  the  pulp  of  the  finger  can  readily  recognize 
the  triangular  slit-like  opening.  Under  ordinary 
circumstances  in  adults  it  will  just  admit  the 
tip    of   the   little    finger.*    The    internal    ring   is 


4  >K Lumbar  Vert. 


:^U.Cofinor<  Iliac  Art 


xt.  iliac  Art. 
ectus  Abdominis 
eEPE.PiCAS.TRic  Act. 

/Iesselbacm's  TciAncue 

COURSE  of  Vas 

e.xt.a&domiaal  r.inc 

Symphysis 

Pubic  Spime 

QlMBER/1AT5LlCAMErtT 
From  rhe  FemORAl.  Qmc. 

Course  o/  vas 
*id  Cord 

--Pemis 

Scrotum 


Fig.  72. — Surface  markings  for  the  inguinal  and  femoral 
canals. 

A.S.S.,  Anterior  superior  spine  of  ilium. 


situated  about  J  an  inch  above  Poupart's  liga- 
ment^ midway  between  the  symphysis  pubis  and 
anterior  superior  iliac  spine.  This  is  the 
femoral  point;  it  lies  directly  over  the  femoral 

*  In  cases  of  congenital  or  acquired  absence  of  the  cord  the  external 
ring  may  be  almost  obliterated.  Paulet  quotes  from  Malgaigne  the  case  of 
an  old  man  whose  testicle  had  been  removed  in  infancy,  and  in  whom  the 
external  ring  was  so  small  as  to  be  scarcely  recognizable. 


XVI] 


INGUINAL    HERNIA 


353 


artery  as  that  vessel  escapes  from  the  abdomen 
beneath  Poupart's  ligament  (Fig.  72). ^ 

There  are  two  principal  forms  of  inguinal  hernia, 
which  can  be  best  understood  by  a  view  of  the 
anterior  abdominal  parietes  from  within  (Fig.  73). 
From  such  an  aspect  it  will  be  seen#  that  the 
peritoneum  is  marked  by  three  linear  ridges  that 
run,  roughly  speaking,  from  the  umbilicus  to  the 


Urachus 
Oblit.  Hypogast.  Art. 


Deep  Epigast. 
Art. 

•Ext.  Fossa 
-Ext.   Iliac  Aht. 
-Mid.  Fossa 

Femoral  Fossa 


Int.  Fossa 
Obturator    Fossa 


Fig.  73. — The  sites  of  hernia  as  seen  on  the  inner  (peri- 
toneal) aspect  of  the  abdominal  wall.     {After  Merkel.) 

pelvic  brim.  One  of  these  ridges  follows  the 
middle  line  from  the  navel  to  the  symphysis  and 
represents  the  urachus ;  a  second,  that  may  be 
indicated  by  a  line  drawn  from  the  femoral 
point  to  the  navel,  represents  the  deep  epigastric 
artery ;  while  between  these  two,  and  much 
nearer  to  the  epigastric  vessel  thanto  the  middle 
line,  is  the  line  formed  by  the  obliterated  hypo- 

ftric  arbery  (Fig.  73).    By  means  of  these  ridges 
M 


354         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

the  peritoneum  is  made  to  present  three  fossse,  an 
external  to  the  outer  side  of  the  epigastric  artery, 
an   internal  between  the   urachus  and  the  hypo- 
gastric artery,    and   a  middle  between  the  track 
of    the    latter    vessel    and    the    epigastric    trunk. 
The  internal  ring  (so  called)  is  just  to  the  outer 
side    of    the    epigastric  _  artery,    and    the    site    of 
the  summit  of  the  inguinal  canal  is  indicated  by 
a  depression  in  the  peritoneum  (Fig.  73).     When 
a  hernia  follows  the   inguinal  canal  throughout 
its  entire   length,    it  is   called    oblique,   indirect, 
or     external;     "oblique"     or     "indirect"     from 
its    taking    the    oblique    direction    of    the    canal, 
"external"    from  the   position   of   its   neck   with 
reference  to  the  epigastric  vessel.     The  coverings 
of  such  a  hernia  would  be  the  same  as  those  oJ 
the    cord,    viz.    the    skin,    the    superficial,    inter- 
columnar,  cremasteric  and  infundibuliform  layers 
of    fascia,    the    subserous    tissue,    and    the    peri- 
toneum.    When  the  hernia  escapes  to  the   inner 
side  of  the   deep   epigastric   artery,   through  the 
space  known  as  Hesselbach's  triangle,  it  is  callec 
a  direct  or  internal  hernia,  for  reasons  that  wiL 
be  obvious.     There  may  be  two   forms  of   direci 
hernia.     In  one  form  the  gut  ©scapes  through  the 
middle     fossa     above     described,     in     the     other 
through  the  inner  fossa  between  the  hypogastric 
artery  and  the  outer  edge  of  the  rectus  muscle. 
The  middle  fossa  is  nearly  opposite  to  the  sum- 
mit  of    the    external    ring.       A    hernia    escaping 
through  that  fossa  would  enter  the  inguinal  canal 
some  little  way  below  the  point  of  entrance  of  an 
oblique  hernia,  and  would  have  the  same  coverings 
as  that  hernia,  with  the  exception  of  the  infundi- 
buliform fascia.     The  first  covering,   indeed,  that 
it  would  receive  from  the  canal  structures  would 
be  the  cremasteric  fascia.       The  inner  fossa  cor- 
responds,   so   far    as   the    inguinal   canal    is   con- 
cerned, with  the  external  ring.     A  hernia  escap- 
ing through  this  fossa  would  be  resisted  by  the 
conjoined    tendon     and  ^  the     triangular     fascia. 
These    structures    are    either    stretched    over    the 


XVI]  INGUINAL    HEKNIA  355 

hernia  so  as  to  form  one  of  its  coverings,  or  the 
conjoined  tendon  is  perforated  by  the  hernia,  or 
lastly  the  gut  deviates  a  little  in  an  outward 
direction  so  as  to  avoid  the  tendon  and  appear  at 
its  outer  side  (Velpeau).  In  any  case  the  hernia 
is  forced  almost  directly  into  the  external  abdo- 
minal ring.  The  coverings  of  such  hernise  are 
the  skin  and  superficial  fascia,  the  intercolumnar 
fascia,  the  triangular  fascia  and  conjoined  tendon 
(with  the  exceptions  above  mentioned),  the  trans- 
versalis  fascia,  subserous  tissue,  and  peritoneum. 

Direct  versus  indirect  inguinal  hernia. — The 
indirect  hernia,  as  just  hinted,  may  be  con- 
genital, the  direct  is  never  congenital.  In  the 
congenital  oblique  hernia  the  outline  of  the#  in- 
guinal canal  and  the  relations  of  the  various 
parts  concerned  are  but  little  disturbed,  and  the 
differences  between  this  form  of  rupture  and  the 
direct  variety  are  conspicuous.  The  acquired 
oblique  hernia,  however,  does  not  present  such  a 
contrast  to  the  direct  form  as  might  be  expected. 
In  the  first-named  rupture,  from  constant  drag- 
ging upon  the  parts,  the  internal  ring  becomes 
more  or  less  approximated  to  the  external  ring, 
and  the  length  of  the  canal,  and  consequently  the 
obliquity  of  the  hernia,  is  considerably  reduced. 
Thus  the  axes  of  the  two  forms  of  rupture  do  not 
present  such  differences  as  to  make  their  nature  at 
once  obvious.  The  direct  hernia,  however,  on  re- 
duction, will  pass  directly  back  into  the  belly, 
while  the  indirect  will,  even  in  old  cases,  take  a 
slight  but  appreciable^  direction  outwards.  After 
the  reduction  of  the  direct  hernia,  the  edge  of  the 
rectus  muscle  may  be  readily  felt  to  the  inner  side 
of  the  aperture,  the  protrusion  being,  indeed,  at 
the  semilunar  line.  The  direct  hernia  is  usually 
small  and  globular,  while  the  oblique  rupture  may 
attain  large  size,  and  tends  to  assume  a  pyriform 
outline. 

Forms  of  oblique  hernia  depending  upon  con= 
genital    defects    in    the    "  vaginal    process."    7yhe 

— 


356 


THE    ABDOMEN    AND    THE    PELVIS     [Chap. 


testis  in  the  foetus  descends  from  the  region  of 
the  kidney  into  the  scrotum  by  a  way  through  the 
abdominal  wall  that  is  afterwards  known  as  the 
inguinal  canal  (see  p.  351). 

Its  descent  is  preceded  by  the  passage  into 
the  scrotum  of  a  process  of  the  peritoneum,  the 
vaginal  process.  The  testicle  usually  enters  the 
internal  ring  about  the  seventh  month  of  foetal 


Sperm.  Vessels  and  Vas 
Int.  Abdom.   Ring 


Proc.  Vaginalis 


Mesentery 

Testis 

Proc.  Vaginalis 


GUBERNACULUM 


Fig.  74. — The  relationship  of  the  processus  vaginalis, 
gubernaculum,  and  plica  vascularis  to  the  testicle  of 
the  human  foetus. 


life,  and  by  the  eighth  month  is  in  the  scrotum. 
The  process  of  descent,  which  was  investigated 
and  made  clear  by  John  Hunter  some  150  years 
ago,  is  often  misunderstood.  The  gubernaculum 
(Fig.  74)  is  a  solid,  bullet-like  plug  of  growing 
tissue  which,  by  a  pure  process  of  growth,  burrows 
its  way  through  the  abdominal  wall  into  the 
scrotum,  carrying  with  it  a  process  of  peritoneum 
— the   processus   vaginalis — with  the   testicle   and 


XVI]  INGUINAL    HERNIA  357 

epididymis  enclosed  within  the  process.  The 
lower  or  growing  end  of  the  gubernaculum  is 
composed  of  rapidly  proliferating  cells;  its  upper 
part,  which  is  attached  to  the  globus  minor  and 
mesentery  of  the  testicle,  is  composed  of  non- 
striated  muscular  tissue.  It  can  be  understood 
that  the  growing  end  of  the  gubernaculum  may 
be  diverted  from  its  course  and  carry  the  testicle 
towards  the  root  of  the  penis,  or  outwards  in 
the  groin,  or  backwards  into  the  perineum.  It 
was  Hunter's  opinion,  and  the  evidence  now 
accumulated  goes  to  support  him,  that  the  pro- 
cess of  descent  is  regulated  by  the  full  develop- 
ment of  the  testicle — probably  by  an  internal 
secretion.  Hence,  if  the  testicle  is  imperfect,  the 
process  of  descent  is  arrested,  the  testicle  being 
left  in  the  abdomen  or  stranded  in  the  inguinal 
canal. 

The  vaginal  process  is  often  found  open  at 
birth;  one  may  infer  from  the  observations  of 
Zuckerkandl  and  of  Sachs  that,  even  in  children 
three  or  four  months  old,  the  communication  re- 
mains open  in  30  to  40  per  cent,  of  cases.  The 
part  of  the  processus  vaginalis  which  surrounds 
the  testicle  becomes  the  tunica  vaginalis,  while  the 
elongated  tubular  part  between  it  and  the  internal 
abdominal  ring  is  known  as  the  processus  funicu- 
laris.  The  manner  in  which  the  processus  vaginalis 
is  cut  off  is  as  follows.  It  becomes  obliterated 
in  two  places,  at  the  internal  ring  and  at  a  spot 
just  above  the  epididymis,  the  obliteration  usually 
beginning  at  the  higher  point  first.  Supposing 
obliteration  to  have  taken  place  at  these  two 
points,  the  vaginal  process  between  them  will  be 
represented  by  an  isolated  tube.  This  soon 
shrinks,  closes,  and  dwindles  to  an  insignificant 
fibrous  cord;  It  may,  however,  remain  patent  in 
part,  and  if  fluid  accumulates  in  this  patent 
portion,  an  "  encysted  hydrocele  of  the  cord  " 
is  produced.  As  regards  the  mode  of  closure, 
three  contingencies  may  happen,  each  giving  rise 
to  a  particular  form  of  hernia  :  (1)  the  "process" 


358         THE    ABDOMEN    AND    THE    PELYIS     [Chap. 

may  not  close  at  all;  (2)  it  may  close  at  the 
upper  point  only ;  and  (B)  it  may  close  at 
the  lower  point  only. 

1.  When  the  vaginal  process  is  entirely  open, 
gut  can  readily  descend  at  once  into  the  scrotum. 
Such  a  condition  is  called  a  congenital  hernia. 
Here  the  intestine  is  found  to  occupy  a  large  sac 
of  the  peritoneum,  the  open  orifice  of  which  is 
placed  at  the  internal  inguinal  ring.  The  term 
"  congenital ;;  is  misleading,  as  the  hernia  is 
very  rarely  present  at  birth,  although  it  is  com- 
mon in  early  life. 

2.  When  the  process  is  closed  only  at  the  in- 
ternal ring  the  unduly  large  tunica  vaginalis 
is  found  to  extend  up  to  that  orifice.  If  a  hernia 
forms  it  may  invaginate  the  processus  vaginalis. 
This  is  known  as  an  infantile  or  encysted^  hernia. 
In  such  a  case  the  tunica  vaginalis  lies  in  front 
of  the  sac,  and  therefore  three  layers  of  peri- 
toneum would  have  to  be  cut  through  before 
the  gut  could  be  reached.  The  term  "  infantile  " 
was  given  to  this  rupture  because  the  first  cases 
reported  were  met  with  in  infants;  the  terra 
"  encysted, "  because  the  hernial  sac  was  con- 
sidered to  be  enclosed  by  the  sac  of  the  tunica 
vaginalis. 

3.  The  funicular  process  may  remain  oper 
from  the  internal  abdominal  ring  to  the  top  ( oi 
the  testicle  and  there  end,  the  normal  tunica 
vaginalis  being  beyond.  Hernia  into  this  process 
is  called  a  hernia  into  the  funicular  process. 

There  is  another  possible  congenital  defect  that 
may  predispose  to  hernia,  viz.  an  abnormally  long 
mesentery.  If,  in  the  dead  subject,  the  inguinal 
canal  be  opened  up,  and  an  attempt  made  to  draw 
a  piece  of  gut  down  from  the  abdomen  into  the 
scrotum,  it  will  be  found  that  this  cannot  be  done, 
owing  to  the  shortness  of  the  mesentery.  In  any 
case  of  scrotal  hernia,  therefore,  the  mesentery 
must  become  lengthened,  and  it  is  a  question 
whether  or  not  an  abnormally  long  mesentery  may 
exist  as  a  congenital  defect,  and  so  predispose  the 


XVIJ  INGUINAL    HERNIA  859 

patient  to  rupture.  More  information  is  required 
upon  the  subject. 

Another  factor  which  must  be  considered  in 
the  production  of  hernia  is  the  tension  or  pressure 
within  the  abdomen.  When  a  labourer  lifts  a 
heavy  weight  from  the  ground,  the  musculature 
of  the  abdomen  is  thrown  into  vigorous  action, 
compressing  the  viscera  and  raising  the  pressure 
within  the  abdomen  to  100  mm.  of  mercury  or 
more.  The  compressed  viscera  seek  out  the 
weakest  points  in  the  abdominal  wall,  which  are 
represented  by  the  internal  abdominal  and  other 
rings.  The  escape  of  viscera  at  the  abdominal 
ring  is  prevented  by  the  conjoined  pa-rts  of  the 
internal  oblique  and  transversalis.  Mr.  George 
Chiene  observed  that  when  a  patient  was  asked 
to  strain,  this  muscle  contracted  vigorously,  so 
that  a  finger  inserted  into  the  inguinal  canal 
was  gripped  between  the  conjoined  tendon  and 
Poupart's  ligament.  Hernise  are  notoriously 
frequent  in  men  who  have  to  lift  and  carry 
heavy  burdens. 

The  inguinal  canal  in  the  female  is  much 
smaller  and  narrower,  although  a  trifle  longer, 
than  it  is  in  the  male.  It  is  occupied  by  the 
round  ligament,  and  offers  such  slight  induce- 
ment to  the  formation  of  a  rupture  that  acquired 
inguinal  hernia  is  as  rare  among  females  as  it  is 
common  among  men.  In  the  female  foetus  a  pro- 
cess of  peritoneum  descends  for  a  little  way  along 
the  round  ligament.  It  corresponds  to  the  pro- 
cessus vaginalis  of  males,  and  is  known  as  the 
canal  of  Nuck.  If  this  process  remains  patent, 
as  it  not  unfrequently  does,  it  may  lead  to  a  rup- 
ture that  corresponds  to  the  congenital  hernia  of 
males.  Indeed,  in  quite  early  life  the  inguinal 
rupture  is  about  the  only  form  met  with  in 
female  children,  if  exception  be  made  of  umbilical 
hernia.  Not  uncommonly  the  ovary  is  found  as 
one  of  the  contents  of  the  hernial  sac — for  in  the 
newly-born  child  the  ovary  lies  above  the  level 
of  the  pelvic  brim  and  relatively  near  the  internal 


360         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

abdominal  ring.  In  all  such  instances  of  early  in- 
guinal hernia  the  gut  has  travelled  down  a  patent 
canal  of  Nuck. 

It  only  remains  to  be  said,  that  in  endeavour- 
ing to  reduce  an  inguinal  hernia  by  taxis  the 
thigh  should  be  flexed  and  adducted,  for  in  this 
position  the  abdominal  parietes  that  bound  the 
inguinal  canal  are  the  most  relaxed.  This  posi- 
tion of  the  thigh  affects  the  inguinal  region 
mainly  through  the  attachments  of  the  fascia  lata 
to  Poupart's  ligament. 

In  herniotomy  an  incision  is  made  along  the 
middle  of  the  tumour  and  in  its  long  axis,  being 
so  arranged  that  its  centre  shall  correspond  to 
the  external  ring.  The  superficial  external  pudic 
\xtery  is  usually  divided  in  the  operation.  It  is 
impossible  to  distinguish  the  various  layers  of 
tissue  that  cover  the  hernia,  the  only  one,  as  a 
rule,  that  is  recognizable  being  the  layer  from 
the  cremaster.  In  dividing  the  constriction  it  is 
usually  recommended  to  cut  upwards  in  all  forms 
of  inguinal  hernia.  The  only  vessel  in  risk  of 
being  damaged  is  the  deep^  epigastric.  In  the 
oblique  form  of  rupture  an  incision  directly^  up- 
wards would  quite  avoid  this  artery ;  but  in  a 
direct  hernia,  where  there  is  reason  to  suppose 
that  the  vessel  is  in  close  connexion  with  the  neck 
of  the  sac,  it  is  well  that  the  incision  be  directed 
a  little  inwards  as  well  as  upwards.  _  It  should 
be  remembered  that  the  incision  required  to  re- 
lieve a  constriction  is,  if  properly  applied,  of  the 
most  insignificant  character. 

2.  Femoral  Hernia.— In  this  form  of  rupture 
the  gut  leaves  the  abdomen  through  the  femoral 
ring  and  passes  down  into  the  thigh  along  the 
crural  canal  (Figs.  72  and  73).  The  name  "  crural 
canal "  is  given  to  the  narrow  interval  between 
the  femoral  vein  and  the  inner  wall  of  the  femoral 
sheath.  Like  the  inguinal  canal,  it  is  a  potential 
rather  than  an  actual  canal,  and  exists  only  when 
the  sheath  has  been  separated  from  the  vein  by 
dissection  or  by  a  hernial  protrusion  of  some  kind. 


XVI]  FEMORAL    HERNIA  361 

The  canal  is  funnel-shaped,  about  i  an  inch  in 
length,  and  ends  opposite  the  saphenous  opening. 
A  point  taken  on  Poupart's  ligament  midway  be- 
tween the  pubic  spine  and  femoral  point  lies 
directly  over  the  femoral  ring;  the  centre  of  the 
saphenous  opening  is  situated  j  of  an  inch  below 
this  point  (Fig.  72).  Femoral  hernise  are  always 
acquired,  and  possess  a  sac,  made  by  themselvep 
out  of  the  parietal  peritoneum  covering  the  crura! 
ring  and  its  vicinity.  The  canal  is  larger  in 
women  than  in  men,  and  thus  it  happens  that 
this  species  of  rupture  is  much  more  common  in 
the  former  sex.  The  tendency  to  this  hernia  in 
women  appears  also  to  be  increased  by  the  weak- 
ening effects  of  pregnancy  upon  the  abdominal 
walls.  As  the  gut  descends  it  pushes  in  front  of 
it  its  sac  of  peritoneum  and  the  septum  crurale 
(the  name  given  to  the  subserous  tissue  that  covers 
in  the  femoral  ring)  and  enters  the  crural  sheath. 
The  adhesions  of  the  sheath  limit  its  downward 
progress  when  it  has  travelled  about  J  an  inch, 
and  it  therefore  passes  forwards  through  the 
saphenous  opening,  pushing  before  it  the  cribri- 
form fascia.  It  then  receives  a  covering  from  the 
superficial  fascia  and  the  skin.  Owing  to  the 
rigidity  of  the  structures  about  the  femoral  ring, 
the  neck  of  the  sac  must  always  be  small.  For 
similar  reasons  its  dimensions  while  in  the  femoral 
canal  must  of  necessity  be  insignificant,  but  when 
once  it  has  escaped  through  the  saphenous  open- 
ing the  loose  subcutaneous  fasciae  of  the  groin 
afford  it  ample  opportunity  for  increase.  When 
the  hernia  has  passed  through  the  saphenous  open- 
ing it  tends  to  mount  upwards  over  Poupart's 
ligament,  in  the  direction  of  the  anterior  superior 
iliac^  spine.  Even  when  it  overlaps  the  ligament 
considerably  it  can  hardly  be  mistaken  for  an 
inguinal  hernia,  since  it  must  always  lie  to  the 
outer  side  of  the  pubic  spine.  The  upward  ten- 
dency of  a  femoral  hernia  has  been  variously 
explained.  It  has  been  ascribed  to  a  supposed 
curve  in  the  crural  canal,  the  concavity  of  which 
M* 


362         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

is  forwards.  Scarpa  believed  it  to  receive  its 
direction  from  the  frequent  flexion  of  the  thigh. 
Probably  one  of  the  most  important  factors  in 
the  matter  is  the  unyielding  character  of  the 
lower  edge  of  the  saphenous  opening.  If  an  elas- 
tic capsule  be  dilated  within  the  femoral  canal 
it  will  be  found  to  turn  upwards  and  inwards 
oyer  Poupart's  ligament;  the  direction  of  expan- 
sion is  determined  by  the  circumstances  just  men- 
tioned and  by  the  yielding  character  of  the  an- 
terior wall  of  the  femoral  sheath.  The  hernial 
sac  is  superficial  to  Scarpa's  fascia. 

Relations* — When  a  hernia  occupies  the  crural 
canal  there  are  in  front  of  it  the  skin  and  super- 
ficial fasciae,  the  iliac  part  of  the  fascia  lata,  the 
cribriform  fascia,  and  the  anterior  wall  of  the 
crural  sheath.  Behind  are  the  posterior  wall  of 
the  crural  sheath  and  pubic  portion  of  the  fascia 
lata,  the  pectineus  muscle,  and  the  bone.  The 
boundaries  of  the  femoral  ring  are,  in  front,  Pou- 
part's  ligament  and  the  deep  crural  arch ;  behind, 
the  bone  covered  by  the  fascia  lata  and  the  pec- 
tineus; on  the  inner  side,  the  conjoined  tendon, 
Gimbernat's  ligament,  and  the  inner  part  of  the 
deep  crural  arch;  on  the  outer  side,  the  femoral 
vein  in  its  sheath  (Figs.  72,  73).  The  spermatic 
cord  lies  (in  the^  male)  just  above  the^  anterior 
border  ^  of  the  ring,  and  the  epigastric  artery 
skirts  its  upper  and  outer  part.  The  little  pubic 
branch  of  this  artery  passes  round  the  ring  to 
ramify  over  Gimbernat's  ligament.  In  two  cases 
out  of  seven  the  obturator  artery  arises  from  the 
epigastric.  In  10  per  cent,  of  cases  the  abnormal 
obturator  passes  on  the  inner  side  of  the  femoral 
ring  and  is  in  danger  of  being  wounded  in  opera- 
tions for  strangulation  ;  in  other  cases  the  artery 
descends  to  the  outer  side  of  the  ring  or  may  cross 
it  (R.  Quain).  In  one  instance  where  the  vessel 
was  placed  internally  to  the  femoral  ring  the  pul- 
sations of  the  abnormal  arterywere  felt  before  the 
parts  were  divided.  In  addition  to  the  vessels 
about  the  ring  there  is  also  a  pubic  vein,  which, 


XVI]  OBTURATOR    HERNIA  363 

ascending  from  the  obturator  vein  in  the  thyroid 
foramen,  enters  the  external  iliac  vein.  Its  rela- 
tion to  the  crural  ring  varies  in  the  same  way  as 
the  abnormal  artery  last  named. 

The  size  of  the  femoral  canal  and  the  degree 
of  tension  of  its  orifices  vary  greatly  with  the 
position  of  the  limb.  If  the  thigh  be  extended, 
abducted,  and  rotated  outwards,  these  parts  are 
made  very  tense,  while  they  are  the  most  lax  when 
the  limb  is  flexed,  adducted,  and  rotated  inwards. 
It  is  consequently  in  the  latter  position  that  the 
thigh  should  be  placed  when  taxis  is  being  at- 
tempted. 

In  herniotomy  the  incision  is  made  along  the 
inner  side  of  the  tumour,  and  is  so  arranged 
that  its  centre  corresponds  to  about  the  upper 
part  of  the  saphenous  opening.  The  constriction 
is  usually  at  the  neck  of  the  sac,  and  caused  by 
Gimbernat's  ligament.  It  is  divided  by  an  in- 
cision  directed   upwards  and  inwards. 

3.  Obturator  hernia.— In  this  form  the  gut, 
pushing  before  it  the  peritoneum,  the  subperi- 
toneal fat,  and  the  pelvic  fascia,  escapes  through 
the  obturator  canal  (Fig.  73).  The  direction  of 
this  canal  is,  from  behind,  downwards,  forwards, 
and  inwards.  The  inguinal  is  separated  from  the 
femoral  canal  by  the  inner  part  of  Poupart's 
ligament;  the  femoral  is  separated  from  the^  ob- 
turator by  the  horizontal  ramus  of  the  pubis. 

Beyond  the  canal  the  hernia  may  pass  between 
the  obturator  membrane  and  the  obturator  exter- 
nus  muscle  and  remain  deeply  placed,  or  it  may 
make  its  way  through  the  muscle  or  emerge  above 
it  and  be  then  covered  by  the  pectineus  and  adduc- 
tor brevis.  The  obturator  artery  is,  as  a  rule, 
at  the  outer  and  posterior  part  of  the  sac.  It  is 
very  rarely  in  front  of  it.  The  obturator  nerve 
is  generally  found  to  the  outer  side  of  the  sac, 
less  commonly  it  is  in  front  of  it.  The  proximity 
of  the  nerve  renders  it  very  liable  to  be  pressed 
upon,  and  pain  along  the  nerve  is  often  a  marked 
feature    of    the    rupture.      The    hernia    presents 


364         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

beneath  the  pectineus  muscle,  to  the  inner  side  of 
the  capsule  of  the  hip,  behind  and  to  the  inner 
side  of  the  femoral  vessels,  and  to  the  outer  side 
of  the  adductor  longus  tendon.  Pain  on  moving 
the  hip  is  generally  a  conspicuous  symptom.  The 
obturator  externus  may  be  made  tense  by  rotation 
inwards  of  the  slightly  abducted  thigh.  This 
hernia  is  much  more  common  in  females;  and  it 
is  worthy  of  note  that  the  orifice  of  the  obturator 
canal  can  be  examined,  to  some  extent,  through 
the  vagina.  Professor  Wood  reports  a  remarkable 
case  where  a  hernial  protrusion  of  a  part  of  the 
adductor  longus  through  a  rent  in  the  fascia  lata 
was  mistaken  for  an  obturator  hernia. 

4.  Rare  forms  of  hernia. — In  perineal  hernia 
the  sac,  covered  by  the  recto-vesical  fascia,  escapes 
through  the  anterior  fibres  of  the  levator  ani 
muscle,  between  the  prostate  and  the  rectum.  In 
the  ischiorectal  hernia  the  protrusion  takes  place 
into  the  ischio-rectal  fossa.  In  pudendal  hernia 
the  sac  lies  in  the  posterior  inferior  half  of  the 
labium  pudendi,  escaping  between  the  ascending 
ramus  of  the  ischium  and  the  vagina ;  it  has  been 
mistaken  for  a  cyst.  In  sciatic  hernia  the  gut 
escapes  through  the  great  sacro-sciatic  notch  in 
front  of  the  internal  iliac  vessels,  above  or  below 
the  pyriformis,  and  appears  under  the  gluteus 
maximus  muscle.  As  regards  umbilical  hernia, 
nothing  remains  to  be  added  to  what  has  been 
already  said  (p.  339),  save  that  the  sac  from  its 
position  nearly  always  contains  omentum,  and 
may  contain  stomach.  In  lumbar  hernia  the  gut 
escapes  in  front  of  the  quadratus  lumborum 
muscle,  and  appears  on  the  surface  through  the 
triangle  of  Petit  (the  gap  between  the  latissimus 
dorsi  and  external  oblique  muscles),  and  there- 
fore just  above  the  highest  point  of  the  iliac  crest. 
The  sac  must  either  force  before  it  or  (in  cases  of 
injury)  come  through  the  fascia  lumborum  and 
internal  oblique  muscles,  since  these  structures 
form  the  floor  of  the  triangle.  The  hernia  may 
escape  through  the   "  upper   lumbar  triangle  " — 


XVI]  RARE    FORMS    OF    HERNIA  365 

a  gap  near  the  last  rib  where  the  aponeurosis  of 
the  transversalis  is  covered  only  by  the  latissimus 
dorsi.  Macready  {Lancet,  Nov.  8th,  1890)  has  col- 
lected twenty-five  examples  of  this  hernia.  Dia= 
phragmatic  herniae*  may  be  congenital  or  acquired. 
The  former  variety  is  by  far  the  more  common,  and 
is  due  to  simple  arrest  in  the  development  of  the 
diaphragm  and  persistence  of  the  original  con- 
nexion between  the  thorax  and  abdomen ;  the 
position  of  this  connexion  is  marked  by  the  fibrous 
interval  between  the  muscular  fibres  arising  from 
the  last  rib  and  those  springing  from  the  external 
arcuate  ligament.  The  congenital  form  very  rarely 
occurs  on  the  right  side,  the  development  of  the 
liver  securing  the  closure  of  the  pleuro-peritoneal 
opening  on  that  side.  In  the  acquired  form, 
which  is  usually  the  result  of  a  crushing  accident, 
the  diaphragm  may  be  lacerated  at  any  point, 
but  in  the  majority  of  instances  the  lesion  is 
situated  in  the  left  dome  over  the  stomach.  In  an 
adult  subject  dissected  by  Dr.  N.  Paterson  the 
abdominal  contents  of  the  left  hypochondrium 
occupied  the  left  pleural  cavity ;  there  was  a  large 
aperture  in  the  left  dome ;  the  condition  had  not 
been  recognized  during  life  and  apparently  had 
given  rise  to  no  marked  symptom.  Of  the  organs, 
the  stomach  is  the  most  frequently  dislodged,  then 
the  transverse  colon,  omentum,  small  gut,  spleen, 
liver,  pancreas,  and  kidneys,  in  the  order  named. 
The  hernia  may  escape  through  the  foramen  for 
the  gullet,  but  never  through  that  for  the  vena 
cava,  nor  through  the  hiatus  aorticus.  A  partial 
hernia  of  the  stomach  through  the  oesophageal 
orifice  is  not  uncommon.  Mr.  W.  A.  E.  Waller 
has  recorded  the  case  of  a  young  man,  aged 
19,  who  died  with  obscure  symptoms  of  obstruc- 
tion. The  stomach  was  found  incarcerated  in 
the  oesophageal  orifice,  the  greater  part  having 
passed  into  the  left  pleural  cavity.  The  parts 
commonly    selected    are    the    connective-tissue    in- 

*  For  a  description  of  the  various  forms,  see  Keith,  Brit.  Med.  Journ  . 
Oct.  2D,  1910.  ' 


366         THE    ABDOMEN    AND    THE    PELVIS     TChap. 

tervals  between  the  sternal  and  costal  origins 
of  the  diaphragm  in  front  and  its  vertebral 
and  costal  origins  behind.  These  hernise  are  more 
common  in  males. 

Femoral  and  inguinal  diverticula. — Re- 
cently Mr.  R.  W.  Murray  has  called  attention  to 
the  frequency  with  which  diverticula  of  peri- 
toneum are  found  over  the  openings  of  the  femoral 
and  inguinal  canals  (see  Fig.  73,  p.  353).  In  200 
post-mortem  examinations  he  found  52  femoral 
and  13  inguinal  diverticula  and  yet  no  hernia. 
In  some  cases  the  inguinal  sacs  may  be  formed 
from  the  processus  vaginalis,  but  all  the  femoral 
forms  and  probably  the  majority  of  the  inguinal 
are  caused  by  yielding  of  the  fibrous  tissue  of  the 
parietes  over  the  femoral  and  internal  abdominal 
rings.  In  these  regions  the  peritoneum  is  so 
loosely  bound  to  the  abdominal  wall  that  it  may 
be  evaginated  by  even  a  low  degree  of  intra- 
abdominal pressure. 

Posterior  Abdominal  Parietes 

The  lateral  and  posterior  walls  of  the  abdo- 
men are  lined  inside  with  two  fascia;,  the 
transversalis  and  iliac.  The  transversalis  fascia 
lines  the  whole  of  the  transversalis  muscle,  and 
is  <  much  thicker  below  than  above.  Above,  it 
joins  the  fascia  covering  the  diaphragm,  while 
below  it  is  attached  to  the  iliac  crest  and  to 
the  whole  of  Poupart's  ligament,  save  at  that 
spot  where  it  passes  into  the  thigh  to  form  the 
anterior  layer  of  the  crural  sheath.  The  iliac 
fascia  encloses  the  ilio-psoas  muscle,  p  the  part 
over  the  psoas  being  the  thinner.'  This  part  is 
attached  on  the  inner  side  to  the  sacrum,  and  to 
the  spine  at  the  points  corresponding  to  the  psoas 
origin.  Above,  it  is  attached  to  the  ligamentum 
arcuatum  internum,  and  on  the  outer  side  to  the 
anterior  layer  of  the  lumbar  fascia  along  the 
outer  edge  of  the  psoas.  Below,  the  fascia  en- 
closes the  iliacus,  and  is  attached  to  the  iliac  crest, 


XVI]      POSTERIOR    ABDOMINAL    PABIETES        367 

to  the  pelvic  brim,  and  to  Poupart's  ligament, 
save  at  that  part  where  the  membrane  passes  be- 
neath the  ligament  to  form  the  posterior  wall  of 
the  crural  sheath.  It  follows  the  ilio-psoas  muscle 
to  its  insertion,  and  ends  by  blending  with  the 
fascia  lata. 

The  arrangement  of  these  fasciae  greatly  influ- 
ences the  progress  and  direction  of  abscess.  Thus 
an  abscess  placed  beneath  the  transversalis  fascia 
will  point  either  just  above  the  iliac  crest  or  Pou- 
part's  ligament,  or  run  down  along  the  spermatic 
cord  and  distend  the  inguinal  canal. 

The  iliac  fascia  encloses  the  ilio-psoas  in  a 
very  distinct  osseo-aponeurotic  space;  Between  the 
fascia  and  the  muscle  (especially  its  iliac  division) 
there  is  a  good  deal  of  loose  connective  tissue, 
and  thus  every  facility  is  offered  for  the  progress 
of  subfascial  abscesses  in  this  region.  The  osseo- 
aponeurotic  space  is  practically  closed  on  all  sides 
within  the  abdomen,  and  is  only  open  below  where 
the  fascia  passes  with  its  muscle  into  the  thigh. 
This  opening  being  at  the  most  dependent  part  of 
the  space,  it  follows  that  the  psoas  or  iliac  abscess 
very  commonly  points  on  the  upper  part  of  the 
thigh,  just  to  the  outer  side  of  the  femoral  vessels. 
An  abscess  in  the  iliac  fossa,  although  most  likely 
to  reach  the  thigh,  might  mount  up  to  the  superior 
attachments  of  the  fascia,  and  point  at  the  iliac 
crest  or  at  the  outer  part  of  Poupart's  ligament. 
Or  it  may  disregard  the  inner  attachments  of  the 
fascia  and  gravitate  into  the  pelvis.  If  the 
patient  should  occupy  for  long  the  recumbent  pos- 
ture, there  is  no  reason  why  it  should  not  extend 
upwards  along  the  psoas  muscle. 

The  term  iliac  abscess,  however,  is  often  ap- 
plied to  collections  that  are  not  within  the  space 
formed  by  the  iliac  fascia,  but  that  are  situated 
rather  in  the  subperitoneal  connective  tissue. 
This  tissue  is  very  extensive  and  lax  in  the  iliac 
fossa  in  order^  to  allow  the  expansion  of  the 
peritoneum  which  necessarily  attends  the  filling 
and    emptying    of    the    caecum,    colon,    bladder, 


368         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

uterus,  and  rectum.  Large  collections  of  puru- 
lent matter  may  form  in  it  or  may  spread  into  it 
from  the  pelvis.  Some  distance  above  Poupart's 
ligament  (lj  to  2  inches)  the  subserous  tissue  be- 
comes dense  and  the  peritoneum  closely  bound 
down.  Hence  such  abscesses  remain  in  the  iliac 
fossa,  bulging  out  the  abdominal  wall  just  above 
Poupart's  ligament,  and  occupying  the  angle 
formed  by  the  union  of  the  iliac  and  transversalis 
fasciae.  In  some  cases  they  are  disposed  to  extend 
into  the  pelvis. 

The  abscess,  when  in  the  subserous  tissue,  is 
brought  in  close  contact  with  certain  of  the  vis- 
cera, especially  with  the  caecum  and  sigmoid 
flexure,  and  into  these  portions  of  the  colon  it 
may  open.  Thus,  I  have  seen  a  case  of  iliac 
abscess  due  to  pelvic  necrosis  that  opened  into  the 
sigmoid  flexure,  and  at  the  same  time  discharged 
through  sinuses  about  the  groin.  In  this  case 
some  pus  passed  by  the  anus,  while  on  the  other 
hand  some  faecal  matter  escaped  by  the  groin. 
Retroperitoneal  abscesses^  in  the  pelvis  (pelvic 
cellulitis)  may  mount  up  into  the  iliac  fossae,  may 
appear  as  "  iliac  abscesses/'  and  may  ultimately 
discharge  themselves  by  many  openings  in  the 
lower  parts  of  the  anterior  abdominal  wall. 

It  may  be  well  to  note  that  the  common  and 
external  iliac  vessels,  the  lymphatics,  and  the 
ureters  are  outside  the  iliac  fascia,  and  rest  upon 
its  abdominal  surface,  while  the  anterior  crural 
nerves  and  abdominal  parts  of  the  lumbar  nerves 
are  within  the  osseo-aponeurotic  space.  Thus  the 
intrafascial  abscess  may,  with  little  difficulty, 
reach  the  thigh  by  following  the  iliac  vessels ; 
while  the  subfascial  collection  would  pursue  the 
anterior  crural  nerve. 

A  psoas  abscess,  or  abscess  within  the  fascial 
sheath  of  the  psoas  muscle,  is  usually  due  to  spinal 
caries,  although  it  may  appear  independently  of 
that  disease.  If  the  lumbar  spine  be  involved  the 
matter  can  pass  directly  into  the  substance  of  the 
muscle,  which  it  will  more  or  less  entirely  destroy. 


XVI]  PSOAS    ABSCESS  369 

If  the  mischief  be  in  the  dorsal  spine,  the  matter 
gravitates  along  the  front  of  the  column  until 
it  reaches  the  diaphragm,  which  it  pierces  by  an 
inflammatory  process.  It  is  now  brought  into  re- 
lation with  the  heads  of  the  psoas,  and  has  to  pass 
through  a  narrow  strait.  The  pus,  following  the 
muscle,  at  last  reaches  the  thigh,  and  usually 
points,  just  below  the  groin,  to  the  outer  side  of 
the  femoral  vessels.  The  substance  of  the  psoas 
may  be  completely  replaced  by  an  abscess  cavity. 

The  abscess,  however,  often  shows  much  varia- 
tion. It  may  avoid  the  psoas,  or  leave  it  when 
once  it  has  entered  it,  and  make  its  way  into 
the  lumbar  region  to  find  an  exit  in  the  loin.  Or 
it  may  extend  into  the  iliac  fossa  and  open  above 
the  groin,  or  mount  up  over  the  iliac  crest  and 
discharge  in  the  gluteal  region.  It  may  pass 
along  the  inguinal  canal  and  be  mistaken  for  a 
hernia.  It  may  sink  into  the  pelvis,  and  may 
open  into  the  bladder,  or  discharge  itself  through 
the  great  sciatic  foramen,  or  through  a  sinus  in 
the  perineum.  Some  of  the  latter  cases  have  led 
to  much  confusion  in  diagnosis,  since  there  would 
appear  to  be  little  connexion  between  caries  of 
the  spine  and  a  perineal  abscess. 

Lumbar  region. — The  muscles  that  form  the 
lateral  and  posterior  walls  of  the  abdomen,  and 
that  fill  in  the  interval  between  the  iliac  crest  and 
the  lowest  rib,  are  the  external  oblique  and  latis- 
simus  dorsi,  the  internal  oblique,  the  transver- 
salis  muscle  with  its  fascia  lumborum,  the  erector 
spinse  and  quadratus  lumborum.  The  distance 
from  the  iliac  crest  to  the  tip  of  the  nearest  rib 
(usually  the  eleventh)  varies  from  3  to  7  cm.,  the 
average  being  4*8  cm.,  a  little  less  than  2  inches 
(Addison). 

The  external  oblique  and  latissimus  dorsi  mus- 
cles are  separated  by  a  small  triangular  interval 
below  (the  triangle  of  Petit),  but  above  they  over- 
lap. The  interval  is  best  marked  in  women.  The 
outer  border  of  the  erector  spinse  affords  a  useful 
landmark  in  the  lumbar  region.     At  the  crest  of 


370         THE    ABDOMEN    AND    THE    PELVIS 


the  ilium  the  outer  border  of  the  quadratus  lum 
borum  extends  an  inch  beyond  the  erector  spinse, 
but  at  the  twelfth  rib  it  lies  an  inch  internally 
to  that  muscle  (Fig.  89,  p.  429).  The  triangle  of 
Petit  is  li  to  2  inches  beyond  the  erector  spinse, 
or  just  behind  the  mid-point  of  the  iliac  crest. 

Between  the  last  rib  and  the  iliac  crest  is 
stretched  the  dense  fascia  lumborunij  the  posterior 
aponeurosis  of  the  transversalis  muscle.  It  is 
pierced  near  the  rib  by  the  last  intercostal  artery 
and  nerve,  and  near  the  ilium  by  the  ilio-hypo- 
gastric  nerve  and  its  accompanying  artery.  It  is 
along  these  structures  that  an  abscess  may  possi- 
bly find  its  way  through  the  fascia  in  certain 
cases.  The  fascia  divides  behind  into  three  layers, 
to  enclose  in  definite  spaces  the  quadratus  and 
erector  spinae  muscles,  the  middle  layer  passing 
between  these  two  muscles  to  the  tips  of  the  trans- 
verse processes.  Within  these  spaces  or  compart 
ments  suppuration  may  be  for  some  time  limited. 
A  lumbar  abscess  commencing  in  some  adjacent 
part,  as  in  the  spine  or  in  the  loose  tissue  around 
the  kidneys,  usually  spreads  backwards  by  pierc- 
ing the  fascia  lumborum  or  the  quadratus  muscle. 

The  author's  operation  for  caries  of  the 
lumbar  vertebrae.  —  The  lumbar  vertebrae,  and, 
possibly,  the  last  dorsal,  may  be  reached  by  an  in- 
cision through  the  loin.  A  vertical  cut  is  made 
along  the  outer  edge  of  the  erector  spinse  muscle. 
The  fibres  of  that  muscle  having  been  drawn 
aside,  the  middle  layer  of  the  fascia  lumborum 
is  incised,  and  the  quadratus  lumborum  is  ex- 
posed. This  muscle  is  divided  vertically,  and  then 
the  front  of  the  vertebrae  may  be  reached  by  in- 
troducing the  finger  under  the  psoas  muscle. 
Through  this  incision  the  author  has  removed  the 
whole  of  the  body  of  the  first  lumbar  vertebra  that 
had  been  separated  as  a  sequestrum  (Med.-Chir. 
Trans.,  1884).  The  lumbar  arteries  are  avoided 
by  keeping  close  to  the  transverse  processes  of  the 
vertebrae.  Through  this  incision  a  psoas  abscess 
may  be  most  conveniently  opened. 


CHAPTER  XVII 

THE    ABDOMINAL    VISCERA 

The  peritoneum.— Certain  of  the  viscera,  as, 
for  example,  the  stomach,  spleen,  and  small  in- 
testine, are  so  closely  invested  with  peritoneum 
that  they  could  not  be  wounded  without  that  mem- 
brane being  wounded  also.  Inflammatory  affec- 
tions of  such  viscera  are  also  very  apt  to  involve 
the  peritoneum.  Other  organs,  such  as  the  kid- 
ney, descending  colon,  pancreas,  etc.,  are  so  im- 
perfectly covered  with  the  serous  membrane  that 
a  wound  of  those  organs  need  not  involve  it,  nor 
need  it  be  implicated  in  even  extensive  inflamma- 
tory changes.  Large  abscesses  may,  for  instance, 
form  about  the  kidney  and  discharge  themselves 
through  the  skin  without  any  peritonitis  being 
induced.  Spontaneous  perforation  of  the  small 
intestine  must  involve  the  peritoneum,  while,  on 
the  other  hand,  the  duodenum  and  ascending 
colon  may  become  perforated,  and  the  matter 
escape  into  the  subserous  tissue  without  the  serous 
membrane  being  in  any  way  involved.  It  is  note- 
worthy in  connexion  with  bacterial  infection  that 
it  is  singularly  easy  to  set  up  inflammation  of 
the  peritoneum  if  the  membrane  be  approached 
from  its  inner  surface,  but  comparatively  difficult 
if  it  be  approached  from  without.  Thus  a  small 
puncture  of  the  membrane  may,  on  the  one  hand, 
lead  to  fatal  peritonitis,  while,  on  the  other,  it 
may  be  extensively  torn  from  its  attachments 
(as  in  ligaturing  the  common  iliac  artery  from 
371 


372         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

the  side)  without  any  peritonitis  following.  Or, 
again,  a  little  pus  escaping  on  the  inner  surface 
of  the  membrane  may  lead  to  inflammation,  while 
the  outer  surface  may  be  bathed  with  pus  for  a 
long  while  (as  in  large  perirenal  abscesses)  with- 
out any  peritonitis  being  produced.  Fluid  is 
rapidly  absorbed  from  the  peritoneal  cavity; 
carmine  particles  are  found  within  the  thoracic 
duct  seven  minutes  from  their  injection  within 
the  cavity;  absorption  takes  place  most  rapidly 
in  the  subdiaphragmatic  area  (Dunbar  and  Eemy). 
Inflammation  of  the  peritoneum  may  lead  to  the 
formation  of  a  great  variety  of  bands  and  ad- 
hesions, beneath  which  pieces  of  intestine  may  be 
caught  and  strangulated. 

The  peritoneum  will  allow  of  very  consider- 
able stretching  if  only  that  stretching  be  effected 
gradually.  This  is  frequently  seen  in  cases  of 
gradual  distension  of  the  bowel,  in  the  formation 
of  the  sac  in  hernia,  and  in  the  growth  of  retro- 
peritoneal tumours.  Abrupt  stretching  of  the 
membrane  leads  to  certain  rupture  of  it.  The 
parietal  peritoneum  may  be  ruptured  by  violence 
without  damage  to  any  of  the  viscera. 

The  great  omentum  is,  from  its  position,  very 
apt  fo  be  wounded.  In  small  wounds  of  the 
front  of  the  belly  it  very  often  protrudes  and  acts 
as  an  excellent  t  plug  to  prevent  the  escape  of 
other  and  more  important  structures.  It  is  often 
found  in  hernia,  especially  in  umbilical  hernia, 
where  it  is  almost  constant.  Its  limits  vary,  and 
it  has  an  inclination  to  the  left  side.  This 
depends  upon  the  fact  that  the  omentum  is 
developed  from  the  mesogaster,  and  accounts  for 
the  fact  that  hernise  containing  omentum  are 
much  more  common  on  the  left  side.  >  The  omen- 
tum, like  the  other  parts  of  the  peritoneum,  is 
apt  to  inflame,  and  to  contract  adhesions  to  the 
neighbouring  parts.  These  adhesions  are  often 
of  the  greatest  service  in  limiting  inflammatory 
and  hemorrhagic  extravasations,  by  matting  the 
bowels  together  and  forming  spaces  between  them. 


XVII]  THE    GREAT    OMENTUM  373 

In  perforation  of  the  bowel  from  disease,  an 
opportune  adhesion  of  the  omentum  over  the 
aperture  may  prevent  escape  of  the  intestinal 
contents. 

Large  masses  of  tissue  may  be  nourished 
through  an  adherent  omentum.  Thus  when  the 
proper  blood  supply  of  an  ovarian  tumour  has 
been  cut  off  by  twisting  of  its  pedicle,  the  growth 
may  be  nourished  through  the  omentum,  if  that 
structure  is  adherent  to  it.  Rutherford  Morri- 
son proposes  to  relieve  congestion  of  the  portal 
circulation  by  setting  up  an  anastomosis  between 
the  omental  vessels  and  the  systemic  circulation. 
When  an  adhesion  between  the  omentum  and 
parietal  peritoneum  is  produced  artificially,  large 
anastomotic  vessels  open  up  and  communicate 
with  the  vascular  network  beneath  the  parietal 
peritoneum,  thus  possibly  relieving  tension  in 
cases  of  obstructed  portal  circulation.  In  cases 
of  obesity  fat  collects  conspicuously  in  the  great 
omentum.  In  hernise  the  omentum  generally  con- 
tracts adhesions  to  the  sac,  and  becomes  irreduc- 
ible, or  it  may  form  a  kind  of  second  sac  about  the 
gut  itself  ("  omental  sac  ")•  The  end  of  the  omen- 
tum, by  becoming  adherent  to  distant  parts,  as  to 
the  pelvic  viscera,  may  form  itself  into  a  firmly 
attached  band,  beneath  which  the  bowel  may  be 
fatally  strangled.  In  like  manner  the  intestine 
has  been  strangulated  through  slits  and  holes  that 
have  developed  in  the  omentum,  usually  as  a  re- 
sult of  inflammatory  adhesions.  The  functional 
meaning  of  the  great  omentum  is  by  no  means 
definitely  established,  but  it  undoubtedly  increases 
the  absorptive  area  of  the  peritoneum,  and  evi- 
dence is  not  lacking  to  show  that  it  takes  an  active 
part  in  repelling  bacterial  invasions  of  the  peri- 
toneal cavity.  Thus,  Dr.  B.  H.  Buxton  found 
that  the  mononuclear  white  corpuscles  of  the 
omentum  of  rabbits  were  soon  laden  with  typhoid 
bacilli  in  cases  where  artificial  cultures  had  been 
introduced  within  the   peritoneal  cavity. 

The  mesentery. — The    parietal    attachment    of 


374  THE    ABDOMEN  AND    THE    PELVIS     [Chap. 

the  mesentery  is  liable  to  some  variation.  The 
point  at  which  this  attachment  commences  above 
is  practically  constant.  It  corresponds  with  the 
ending  of  the  duodenum,  is  about  on  a  level  with 
the  lower  border  of  the  pancreas,  and  is  just  to 
the  left  of  the  second  lumbar  vertebra.  (See  p.  379.) 
From  this  point  the  insertion  of  the  mesentery 
follows  an  oblique  line  that  runs  downwards 
and  to  the  right,  crossing  the  great  vessels,  and 
then  ending  in  a  somewhat  uncertain  manner  on 
the  right  iliac  fossa  (Fig.  75,  p.  376).  The  parietal 
attachment  of  the  mesentery  measures,  as  a  rule, 
about  6  inches.  From  its  oblique  attachment  it 
follows  that,  when  haemorrhage  takes  place  in  the 
abdomen  on  the  right  side  of  the  mesentery,  the 
blood  first  is  conducted  into  the  right  iliac  fossa; 
when  on  the  left  side,  into  the  pelvis.  This  may 
explain  the  circumstance  that  collections  of  blood 
are  more  common  in  the  right  than  in  the  left 
iliac  fossa. 

The  length  of  the  mesentery  from  the  spine  to 
the  bowel  varies  in  different  parts  of  the  canal ; 
its  average  length  is  8  inches.  The  longest  part 
is  that  which  goes  to  the  coils  of  intestine  that 
lie  between  a  point  6  feet  from  the  duodenum,  and 
a  point  11  feet  from  the  same  part  of  the  gut 
(Author).*  Such  coils  will,  therefore,  include 
5  feet  of  the  intestine,  and  the  mesentery  here 
may  reach  the  length  of  10  inches.  These  coils 
are  apt  to  hang  in  the  pelvis,  and  may  be  easily 
herniated.  The  length  of  the  mesentery  plays  an 
important  part  in  hernia.  If  the  fresh  body  of 
an  adult  be  opened,  and  the  condition  of  the  vis- 
cera and  peritoneum  be  normal,  it  will  be  found 
that  it  is  impossible  to  drag  a  loop  of  small  in- 
testine through  the  femoral  canal  (artificially^  en- 
larged) on  to  the  thigh,  or  down  the  inguinal 
canal  into  the  scrotum.  In  fact,  no  coil  can,  in 
any  part,  be  drawn  out  of  the  abdomen  below  a 
horizontal  line  on  a  level  with  the  spine  of  the 

*  See  "  The  Anatomy  of  the  Intestinal  Canal  and  Peritoneum  in  Man," 
by  the  Author.    London,  1885. 


XVII]  THE    MESENTERY  375 

pubes.  It  is  evident,  therefore,  that  in  femoral 
or  scrotal  hernia  the  mesentery  must  be  elongated 
or  its  attachments  lowered. 

The  mesentery  is  relatively  longest  in  infancy 
and  childhood,  and  a  freer  escape  of  the  intestines 
from  the  abdomen  is  allowed  in  subjects  under 
puberty.  The  disposition  of  the  membrane  per- 
mits also  a  freer  downward  excursion  of  the 
bowels  on  the  right  side,  and  this  has  been  offered 
as  an  explanation  of  the  undue  frequency  of  right- 
sided  inguinal  hernise  in  childhood  (Lockwood). 

Mr.  Lockwood  states  that  in  acquired  hernia 
the  mesentery  is  found  to  have  had  its  attachments 
lowered  rather  than  to  have  been  increased  in 
length. 

Certain  holes  are  sometimes  found  in  the 
mesentery,  through  which  intestine  has  been 
strangulated.  Some  of  these  holes,  especially 
those  that  are  slit:like,  are  due  to  injury,  others 
are  due  to  congenital  defect  of  the  mesentery. 

Cases  of  imperfect  attachments  of  the  mesen- 
tery have  been  frequently  recorded  of  late  years. 
The  primary  attachment  is  at  the  origin  of  the 
superior  mesenteric  artery,  from  which  a  process 
of  fixation  extends  during  foetal  life  towards  the 
right  iliac  fossa.  If  this  process  is  completely 
arrested  then  the  whole  intestine  may  become 
rotated  round  the  superior  mesenteric  artery, 
causing  obstruction  of  the  bowel,  or,  if  the 
lower  part  of  the  mesentery  is  unattached,  the 
loop  formed  by  the  lower  part  of  the  ileum  and 
commencement  of  the  great  bowel  may  undergo 
a  rotation  and  cause  obstruction. 

Peritoneal  spaces  and  communications. — 
Owing  to  the  arrangement  of  the  peritoneum  the 
cavity  of  the  abdomen  is  divided  into  a  number 
of  potential  spaces  which  are  connected  together 
by  certain  definite  communications  or  routes. 
Alimentary  contents,  pus,  or  blood  escaping 
within  the  peritoneal  cavity  tend  to^  collect  in 
certain  of  these  spaces  and  overflow  into  neigh- 
bouring spaces  in  well-defined  directions.     Some 


376 


THE    ABDOMEN    AND    THE    PELVIS     [Chap. 


writers  see  in  this  arrangement  of  the  peritoneum 
a  resemblance  to  the  watersheds  of  a  country,  and 
hence  the  potential  spaces  and  routes  are  some- 


5ple/iic  Flexure 
Duode/ioJej.  Flexure 


G 

Paracolic  Croove 


Fig.  75. — Diagram  showing  the]  average  position  of  the 
abdominal  viscera  with  their  surface  markings.  (After 
Addison.) 

A,  Sterno-ensiform point ;  A' A',  sterno-ensiform  line  :  B,  mid-epigastric 
point ;  B'B',  mid-epigastric  or  transpyloric  line ;  C,  umbilical 
point ;  C'C',  umbilical  line  ;  D,  mid-hypogastric  point ;  D'D',  mid- 
hypogastric  line  ;  E,E,  outer  border  of  the  right  and  left  rectus 
abdominis  ;  F,  Monro's  point — on  the  right  spino-umbilical  line 
at  the  outer  border  of  the  rectus  abdominis. 


times  spoken  of  as  the  "  watersheds  of  the  peri- 
toneum. "  The  chief  of  these  spaces  are  :  (1)  The 
lesser  sac.  This  communicates  with  (2)  the  sub- 
hepatic space  by  the  foramen  of  Winslow ;  the  space 


XVII]  PEEITONEAL    SPACES  377 

is  bounded  above  by  the  under  surface  of  the 
iiver  and  below  by  the  duodenum,  hepatic  flexure 
of  colon,  transverse  mesocolon,  right  kidney,  and 
right  costo-phrenic  ligament  (Fig.  75).  (3)  The 
right  subphrenic  space  between  the  diaphragm 
and  liver;  it  is  bounded  towards  the  middle  line 
by  the  falciform  and  coronary  ligaments;  below 
it  opens  into  the  subhepatic  space.  (4)  The  left 
subphrenic  space,  between  the  diaphragm  above 
and  left  lobe  of  liver  and  stomach^  below ;  it  is 
separated  from  the  corresponding  right  space  by 
the  falciform  ligament ;  below  it  communicates  with 

(5)  the  perisplenic  space;  this  space  is  bounded 
below  by  the  splenic  flexure  and  its  mesocolon, 
the  left  costo-phrenic  ligament  and  left  kidney. 
These  five  spaces  lie  in  the  supra-omental  region 
of  the  abdomen — above  the  transverse  mesocolon ; 
below  the  transverse  mesocolon  there  are  two  spaces, 
normally   occupied   by   small    intestine ;    they   are 

(6)  the  right  infra-omental,  bounded  above  by  the 
transverse  mesocolon,  below  and  to  the  left  by  the 
duodeno-jejunal  junction  and  root  of  the  mesen- 
tery ;  (7)  the  left  infra-omental,  bounded  above  by 
the  transverse  mesocolon;  it  is  separated  from 
the  right  space  by  the  duodeno-jejunal  junction 
and  mesentery  of  the  small  bowel.  The  remaining 
space — the  eighth — lies  in  the  pelvis,  the  recto- 
uterine in  the  female,  the  recto-vesical  in  the  male. 
Communications  between  the  supra-  and  infra- 
omental  spaces  exist  only  at  the  two  extremities 
of  the  transverse  mesocolon.  Overflow  from  the 
subhepatic  spaces  tends  to  pass  down  the  groove 
external  to  the  ascending  colon  (right  external 
paracolic  groove) ;  by  that  groove  it  reaches  the 
iliac  fossa ;  from  the  iliac  fossa,  the  pelvic  space ; 
from  the  pelvis  it  may  mount  to  the  left  infra- 
omental  pouch,  and  from  there  the  fluid  matter 
may  make  its  way  to  the  left  external  paracolic 
groove  and  thence  to  the  perisplenic  space.  In 
this  description  the  writings  of  Barnard,  Wallace, 
Box,  Jenkins,  and  Maynard  Smith  have  been 
followed. 


378 


THE    ABDOMEN    AND    THE    PELVIS     [Chap. 


Surface  markings  of  the  abdominal  vis- 
cera.—In  F ig.  75  >  is  shown  the^  position  of  the 
abdominal  viscera  in  an  average  individual,  while 


Fig.  76. — Diagram  showing  the  position  of  the  viscera  in 
the  condition  of  visceroptosis. 

A,A,  Sterno-ensif orm  line :  it  crosses  above  the  fifth  costal  cartilage  ; 
B,B,  mid-epigastric  line ;  C,C,  umbilical  line  ;  D,D,  mid-hypo- 
gastric  line  ;  a,  pericardium  ;  b,  stomach  (greatly  elongated  and 
dilated)  ;  c,  liver ;  c',  Biedel's  lobe  ;  d,  duodenum  ;  e,  caecum  ; 
/,  transverse  colon ;  g,  rectum ;  h,  elongated  gastro-hepatic 
omentum. 

in  Fig.  76  is  represented  the  position  assumed  by 
these  viscera  in  a  well-marked  case  of  visceroptosis 
(Glenard's  disease).   Study  of  such  cases,  especially 


XVII]  ABDOMINAL    VISCERA  379 

with  the  aid  of  X-rays,  shows  the  need  of  an 
accurate  and  simple  method  of  indicating  the 
normal  position  of  the  abdominal  contents.  The 
upper  limit  of  the  viscera  is  best  indicated  by  the 
sterno-ensiform  point  and  line.  The  position  of 
the  sterno-ensiform  point  is  indicated  by  a  dis- 
tinct depression  under  the  insertion  of  the  seventh 
pair  of  costal  cartilages;  the  sterno-ensiform  line 
is  drawn  transversely  on  the  body  through  this 
point  and  should  cross  _  the  fifth  pair  of  costal 
cartilages  if  the  thorax  is  of  normal  shape.  The 
right  dome  of  the  diaphragm,  in  the  standing 
posture,  reaches  this  line ;  the  left  dome  is 
i  an  inch  below  it;  in  the  supine  position 
the  domes  rise  upwards  \  an  inch.  The  central 
tendon  is  \  an  inch  below  the  sterno-ensiform 
point.  In  visceroptosis  the  domes  of  the  dia- 
phragm and  viscera  within  them  sink  downwards 
until  they  lie  1  inch  or  more  below  their  normal 
position  (see  Fig.  76).  The  mid-epigastric  point 
is  taken  on  the  linea  alba  half-way  between  the 
umbilical  and  sterno-ensiform  points;  the  mid- 
epigastric  line  (transpyloric  plane  of  Addison) 
crosses  the  body  at  this  point;  it  marks  the  level 
of  the  pylorus  and  pancreas,  with  the  beginning 
and  termination  of  the  duodenum  (Fig.  75).  In 
visceroptosis  the  parts  sink  until  they  reach  the 
umbilical  line  (Fig.  76).  The  umbilical  line,  drawn 
through  the  umbilicus,  usually  crosses  somewhat 
below  the  highest  point  on  the  iliac  crests;  the 
transverse  colon  and  duodenum  cross  the  abdomen 
above  the  line,  the  bifurcation  of  the  aorta  is 
below  it.  In  visceroptosis  the  transverse  colon 
and  duodenum  descend  well  below  the  umbilical 
line  (Fig.  76).  The  mid-hypo  gastric  point  is  taken 
on  the  linea  alba  half-way  between  the  umbilicus 
and  symphysis  pubis ;  it  lies  about  1  inch  below 
the  promontory  of  the  sacrum.  The  mid-hypo- 
gastric  line  crosses  the  iliac  colon  in  the  left  groin 
and  the  fundus  of  the  caecum  in  the  right.  The 
outer  border  of  the  rectus  abdominis  (linea  semi- 
lunaris) also  serves  as  a  useful  guide ;  at  the  point 


380         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

where  it  crosses  the  costal  margin  on  the  right 
side  {right  costo-rectal  point)  is  situated  the  gall- 
bladder; on  the  left  side  the  greater  curvature  of 
the  stomach  emerges  from  the  hypogastrium  at 
this  point  (Fig.  75).  A  line  drawn  from  the 
umbilicus  to  the  right  anterior  superior  iliac  spine 
(spino -umbilical  line)  provides  a  useful  guide  to 
the  ileo-csecal  region.  Monro's  point  is  situated 
on  this  line  at  the  outer  border  of  the  rectus 
abdominis;  the  ileo-csecal  orifice  lies  to  the  right 
of  Monro's  point  immediately  below  the  spino- 
umbilical  line. 

The  viscera  are  maintained  in  position 
by  the  action  of  several  structures,  but  by  far  the 
chief  are  the  muscles  of  the  abdominal  wall — the 
external  and  internal  oblique,  transversalis,  rec- 
tus abdominis;  diaphragm,  and  levator  ani.  By 
their  contraction  or  tonus  they  maintain  the  vis- 
cera firmly  pressed  together ;  in  the  upright  pos- 
ture the  weight  of  the  upper  viscera  rests  on  the 
lower  viscera.  That  the  muscles  are  the  chief 
agents  in  maintaining  the  viscera  in  position  can 
be  shown  in  many  ways.  In  rising  from  the  supine 
to  the  upright  posture  the  upper  viscera  and 
diaphragm  are  seen  in  the  living  body  (by  aid  of 
X-rays)  to  descend  about  J  an  inch  or  more.  When 
the  muscles  and  belly  walls  are  cut  away,  and  the 
dead  body  raised  to  the  upright  position,  all  the 
viscera  drop  downwards  to  the  extent  of  2  inches 
or  more.  The  peritoneal  ligaments,  reflections, 
omenta,  and  mesenteries  merely  limit  the  degree 
of  movement ;  the  viscera  are  freely  movable  to 
allow  the  extensive  respiratory  action  of  the  dia- 
phragm. Besides  the  peritoneal,  there  are  other 
visceral  supports  formed  by  vessels  and  their 
sheaths  of  connective  tissue,  such  as  the  attach- 
ment of  the  liver  to  the  diaphragm  by  the  in- 
ferior vena  cava,  the  kidneys  and  small  intestine 
to  the  posterior  abdominal  wall  by  their  vessels. 
It  is  only  when  the  muscles  of  the  belly  wall  are 
thrown  out  of  action  that  any  strain  or  weight 
falls  on  the  peritoneal  and  vascular  supports. 


XVII]  EELATIONS    OF    THE    STOMACH  381 

The  stomach.— Its  relationships  are  : — 

Above. 
Liver,  small  omentum,  diaphragm. 

Behind. 
In  front.  Transverse      mesocolon, 

(From  left  to  right)  dia-         ^tOlll*l*»h  lesser      sac,      pancreas, 

phragm,  abdominal  wall,         »■»«■■■«»*>■■•        crura,  solar  plexus,  great 
liver.  I vessels,  spleen,  left  kid- 

ney, and  suprarenal. 
Below. 
Great  omentum,  small  intestines,  transverse  colon,  gastro-splenic 
omentum. 

The  oesophagus  perforates  the  diaphragm 
slightly  to  the  left  of  the  middle  line  and  ends  at 
the  cardiac  orifice  of  the  stomach,  3  to  4  inches 
deep  to  the  terminal  inch  of  the  seventh  left  costal 
cartilage.  The  pyloric  orifice,  permanently  closed 
by  its  sphincter  except  when  the  contents  of  the 
stomach  are  passing  to  the  duodenum,  is  situated 
on  the  mid-epigastric  plane  and  about  1  inch  to 
the  right  of  the  linea  alba  in  the  dead  body,  but 
in  the  living,  especially  in  the  upright  posture, 
its  position  is  lower,  being  slightly  to  the  right 
of  the  linea  alba  and  about  2  inches  above  the 
umbilicus  (see  Fig.  75).  Being  situated  under  the 
quadrate  lobe  of  the  liver  and  bound  to  the  trans- 
verse fissure  by  the  gastro-hepatic  omentum,  en- 
largement or  displacement  of  the  liver  necessarily 
causes  a  displacement  of  the  pylorus;  in  cases  of 
visceroptosis  it  may  drop  to  the  umbilical  line 
(Fig.  76).  Normally  the  lesser  curvature^  is  over- 
lapped by  the  liver,  and  the  gastro-hepatic  omen- 
tum is  hid  (Fig.  75),  but  when  the  stomach  be- 
comes dilated,  elongated,  or  falls  down,  the  lesser 
curvature  and  gastro-hepatic  omentum  are  ex- 
posed (Fier.  76).  A  curved  line  drawn  from  the 
position  ofthe  cardiac  orifice  (on  the  seventh  left 
costal  cartilage,  1  inch  from  the  sternum)  to  the 
position  of  the  pylorus  (mid-way  between  the  epi- 
gastric point  and  right  costal  margin)  indicates 
the  normal  position  of  the  lesser  curvature.  While 
the  lesser  curvature  is  comparatively  fixed,  owing 
to  the  attachment  of  the  gastro-hepatic  omentum, 


382         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 


the  greater  curvature  is  freely  movable;  its  posi- 
tion alters  as  the  stomach  is  full  or  empty,  con- 
tracted or  relaxed.  The  variable  position  of  the 
great  curvature  as  seen  in  the  living  is  repre- 
sented in  Fig.  77  from  observations  made  by 
Dr.  A.  F.  Hertz.  When  the  patient  is  standing, 
the  great  curvature  descends  to  the  umbilicus 
or  below  it;  when  lying  down,  the  great  curva- 
ture is  an  inch  or  more  above  the  umbilicus. 
Simple  dilatation  of  the  stomach  leads  to  a  low 
position  of  the  greater  curvature  without  altering 


Fig.  77. — Radiographic  outline  of  the  stomach  of  a  patient 
who   has    taken    a    bismuth-laden    diet.       (After    Dr. 

A.  F.  Hertz.') 

A,  Standing  position  ;  B,  horizontal  position. 

the  position  of  the  lesser  curvature;  in  ptosis  of 
the  stomach  both  curvatures  descend,  but  the 
greater  descends  more  owing  to  dilatation  being 
always  present  (Fig.  76).  In  ptosis^  the  curva- 
tures become  more  vertical  in  position  (Fig. 
76). 

The  shape  of  the  stomach  depends  on  many 
conditions  :  on  its  state  of  physiological  activity, 
on  the  pressure  of  surrounding  organs,  and  on 
its  degree  of  fullness.  In  life,  its  cardiac  and 
pyloric  parts  react  differently  during^  digestion ; 
the   cardiac   part,    which   is  vertical   in   position 


XVII]  THE    STOMACH  383 

and  constitutes  about  two-thirds  of  the  organ, 
undergoes  merely  a  tonic,  not  a  peristaltic,  con- 
traction. The  pyloric  part,  tubular  in  shape  and 
horizontal  in  position,  is  the  seat  of  constant  peri- 
staltic waves  during  digestion.  These  waves  sweep 
towards  the  duodenum  along  the  pyloric  division. 
The  point  at  which  they  begin  is  often  found 
contracted  after  death,  and  this  observation  has 
given  rise  to  the  opinion  that  the  cardiac  and 
pyloric  divisions  are  separated  by  a  mid-gastric 
sphincter.  When  food  is  swallowed,  it  passes  at 
once  into  the  pyloric  division,  and,  as  more  food 
is  taken,  both  divisions  of  the  stomach  fill  (Dr. 
A.  F.  Hertz  and  Dr.  A.  E.  Barclay).  The  fundus 
of  the  stomach,  lying ^  in  the  #  left  dome  of  the 
diaphragm,  contains  air  both  in  the  resting  and 
active  stomach.  When  empty  the  stomach  may  be 
found  to  be  diastolic  or  systolic;  if  systolic  it  is 
usually  covered  by  the  transverse  colon,  and  does 
not  present  when  the  epigastrium  is  laid  open. 
The  two  extremities  of  the  stomach  are  its  most 
fixed  points.  The  cardiac  extremity  is  loosely 
fixed  to  the  diaphragm  by  the  oesophagus,  lax 
periesophageal  tissue,  and  gastro-phrenic  reflec- 
tions of  peritoneum;  the  pyloric  end  is  fixed  to 
the  liver  and  posterior  abdominal  wall  by  the 
gastro-hepatic  omentum,  by  the  hepatic  branch  of 
the  cceliac  axis  and  the  tissue  surrounding  that 
vessel.  The  close  relations  of  the  stomach  to  the 
diaphragm  and  thoracic  viscera  serve  in^  part  to 
explain  the  shortness  of  breath  and  possible  pal- 
pitation of  the  heart,  etc.,  that  may  follow  upon 
distension^  of  the  organ  (Fig.  75,  p.  376).  ^  The 
near  proximity  of  the  heart  to  the  stomach  is  illus- 
trated by  a  case  where  a  thorn  (of  the  Prunus 
spinosa),  J  an  inch  long,  had  been  swallowed  and 
had  then  found  its  way  through  the  diaphragm 
and  pericardium  into  the  wall  and  cavity  of  the 
right  ventricle. 

The  viscus  is  susceptible  of  enormous  dilatation 
when  the  pylorus  is  obstructed.  The  distended 
organ  may  reach  as  low  as  Poupart's  ligament. 


384         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

The  stomach  rests  behind  on  the  lesser  sac  of 
the  peritoneum,  which  plays  the  part  of  a  bursa 
to  it.  Gastric  ulcers  rarely  perforate  into  the 
lesser  sac,  but  when  they  do  the  contents  can  only 
escape  by  the  foramen  of  Winslow,  and  may  not 
be  seen  when  the  abdomen  is  opened.  The  sac 
is  opened  by  incising  the  great  omentum  at  the 
greater  curvature  of  the  stomach. 

The  stomach  has  been  frequently  wounded.     In 
most  cases   a   fatal   result  rapidly   follows   upon 
these   injuries,    for   the   contents   of   the   stomach 
escape  into  the  peritoneal  cavity  and  set  up  an 
acute  peritonitis.     The  most  certainlv  and  rapidly 
fatal    cases,    therefore,    are    those    in    which    the 
stomach  was  full  of  food  at  the  time  of  the  acci- 
dent.    The  empty   stomach,  t  being   deeply   placed 
and  lying  against  the  posterior  abdominal  wall  in 
a  collapsed  state,  is  but  little  exposed  to  injury. 
A  small   punctured  wound  of  the  stomach  need 
not  be  followed  by  escape  of  contents,   since  the 
loosely    attached    mucous    membrane    may    escape 
from  the  wound  and  effectually  plug  it.     This  was 
illustrated  many  times  in  the  Boer  War,  the  viscus 
having  been  perforated  by  a  Mauser  bullet.     The 
stomach   has    protruded   through    wounds    in    the 
abdominal  walls,  and  has  been  returned,  with  no 
evil   results  following.     In   a  few  cases  the  belly 
wall  in  front  of  the  stomach  has  been  wounded, 
the   viscus  has  protruded,    its   anterior   wall  has 
been  wounded  by  the  same  injury  that  penetrated 
the  parietes,  anda  fistulous  opening  leading  into 
the    stomach    cavity  ^  has    resulted.     The    best   ex- 
ample of  such  cases  is  afforded  by  the  well-known 
instance  of  Alexis  St.   Martin,  the  subject  of  so 
many  physiological  experiments.     In  this  man  the 
abdominal  parietes  in  front  of  the  stomach  were 
torn  away  by  a  gunshot  wound,  a  part  of  the  an- 
terior wall  of  the  stomach  sloughed,   and  a  per- 
manent fistula  resulted.     Dr.    Murchison   reports 
the  case  of  a  woman   in   whom  a  gastric  fistula 
was  produced  by  the  continued  pressure^  of  a  cop- 
per coin  worn  over  the  epigastric  region.     This 


XVII 1        LYMPHATICS    OF   THE    STOMACH  385 

coin  was  deliberately  worn  by  the  patient  in  order 
to  excite  a  lesion  that  would  arouse  the  sympathy 
of  her  friends.  The  pressure  led  to  an  ulcera- 
tion that  finally  opened  up  the  stomach.  In  many 
cases  the  fistula  has  been  due  to  ulcerative  diseases 
commencing  in  the  stomach  itself  and  spreading 
outwards. 

Some  remarkable  cases  have  been  recorded 
where  foreign  substances  have  been  swallowed  and 
have  lodged  in  the  stomach.  Certain  of  these 
cases  serve  to  illustrate  the  capacity^  of  the 
stomach,  and  among  the  most  striking  is  an  in- 
stance where  the  viscus^  at  death  was  found  to 
contain  thirty-one  entire  spoon-handles,  each 
about  5  inches  long,  four  half-handles,  nine  nails, 
half  an  iron  shoe-heel,  a  screw,  a  button,  and  four 
pebbles.  The  whole  mass  weighed  2  lb.  8  oz.  Th^ 
patient  was  a  lunatic. 

Lymphatics  of  the  stomach. — The  stomach  is 
abundantlv  supplied  with  lymphatics,  which  com- 
mence in  the  mucous  coat  and  form  plexuses  in 
the  submucous  and  muscular  strata,  from  which 
efferent  vessels  pass  to  glands  along  the  lesser 
and  greater  curvatures.  By  these  vessels  primary 
cancers  of  the  stomach  spread,  _  and  hence  their 
connexions  become  of  surgical  importance.  The 
distribution  of  the  glands  connected  with  the 
stomach  is  shown  in  Fig.  78.  The  chief  group 
— the  coronary — is  situated  near  the  oesophageal 
orifice  and  along  the  upper  part  of  the  lesser 
curvature.  The  afferent  vessels  of  this  group  are 
shown  in  Fig.  78;  the  efferent  vessels  pass^  with  the 
coronary  artery  to  the  suprapancreatic  group 
behind  the  lesser  sac  and  near  the  origin  of  the 
cceliac  axis  from  the  aorta.  The  subpyloric  group 
is  situated  below  and  behind  the  pylorus.  It 
receives  afferent  vessels  from  glands  along  the 
greater  curvature  (right  gastro-epiploic),  and  from 
the  pylorus  and  duodenum;  its  efferent  vessels 
pass  with  the  hepatic  artery  to  the  suprapan- 
creatic aroup,  and  some  also  end  in  the  superior 
mesenteric  group   at  the   origin   of  the   superior 

N 


386         THE    ABDOMEN    AND    THE    PELVIS     [Chap 

mesenteric  artery.  The  efferent  vessels  of  the 
subpyloric  group  are  joined  by  the  lymphatics 
from  the  liver  (see  Fig.  78).  (Jamieson  and 
Dobson.) 

Gastrotomy  and  gastrostomy. — Gastrotomy  con- 
sists   in    opening    the    stomach    through   the    an- 


Fig.  78. — The  groups  of  lymphatic  glands  connected  with 
the  stomach.     {Prof.  J.  K.  Jamieson  and  Mr.  J.  F.  Dobson.) 

terior  abdominal  wall  for  the  purpose  of  removing 
a  foreign  body,  for  making  an  examination,  or 
for  dealing  with  a  simple  or  malignant  ulcer; 
gastrostomy,  in  opening  the  stomach  in  a  like 
situation  with  the  object  of  establishing  a  gastric 
fistula  through  which  the  patient  may  be  fed  in 
cases  where  the  gullet  is  occluded  by  disease.  The 
uncovered  part  of  the  stomach,  accessible  in  these 


XVII]  THE    PYLOEUS  387 

operations,  is  represented  by  a  triangular  area, 
bounded  on  the  right  by  the  edge  of  the  liver,  on 
the  left  by  the  cartilages  of  the  eighth  and  ninth 
ribs,  and  below  by  a  horizontal  line  passing 
between  the  tips  of  the  tenth  costal  cartilages 
(Fig.  75).  The  incision  in  these  operations  must 
be  situate  in  this  triangle,  and  may  be  made 
either  parallel  to  and  about  two  fingers'  breadth 
from  the  free  border  of  the  costse,  or  along  the 
left  semilunar  line.  In  the  former  incision  the 
three  flat  muscles  of  the  abdomen  are  cut  through. 
In  gastrostomy  the  stomach  is  not  opened  at  the 
time  of  the  operation,  but  is  merely  secured  to  the 
wound,  and  a  few  days  are  then  allowed  to  elapse 
so  that  adhesions  may  form.  At  the  end  of  this 
time  the  viscus  is  opened.  The  opening  must 
needs  be  very  small. 

The  pylorus  is  normally  in  a  closed  state, 
and  should,  when  open,  be  capable  of  taking 
the  forefinger.  In  spite  of  the  narrowness  of 
the  pylorus,  large  substances  that  have  been 
swallowed  have  been  passed  by  the  anus  without 
trouble.  Among  these  may  be  noted  a  metal 
pencil-case,  4j  inches  long,  10  ounces  of  garden 
nails,  and  fragments  of  crockery-ware  swallowed 
by  a  lunatic;  a  fork,  a  door-key,  and  other 
strange  bodies.  Needles  and  similar  sharp  sub- 
stances that  have  been  swallowed  have  travelled 
out  of  the  stomach  or  bowels  m  and  have  found 
their  way  to  the  surface  at  various  points  in  the 
body.  In  a  patient  under  my  care  at  the  London 
Hospital  I  extracted  from  beneath  the  skin,  near 
the  groin,  a  needle  swallowed  some  months  pre- 
viously. In  a  case  reportedin  the  Lancet  a  needle 
was  extracted  from  the  middle  of  the  thigh  six 
months  after  it  had  been  swallowed;  and  like 
instances  are  recorded  elsewhere. 

Hypertrophy  may  take  place  in  the  pyloric 
sphincter,  leading  to  the  functional  stenosis  of  the 
orifice.  It  occurs  soon  after  birth,  and  its  cause 
has  to  be  sought  for  in  the  reflex  mechanism  which 
regulates    it.     It    is   not   easy    to   tell    when    the 


388         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

sphincter  is  hypertrophied,  because  the  thickness 
of  the  circular  layer  depends  on  the  degree  of 
contraction  at  death.  In  a  normal  child  of  three 
months  the  circular  layer  of  the  sphincter  varies 
from  1  to  2  mm.  in  thickness  at  the  pylorus,  and 
extends  along  the  pyloric  canal  for  25  mm.  (1 
inch)  ;  if  the  thickness  is  over  3  mm.  the  sphincter 
may  be  regarded  as  hypertrophied  (L.  Mackey). 
Relaxation  of  the  sphincter  normally  follows  when 
the  chyme  expelled  from  the  stomach  has  been 
neutralized   in   the   duodenum. 

Resection  of  the  pylorus. — The  pylorus  is  fre- 
quently the  seat  of  cancer.  As  a  means  #  of  re- 
lieving the  patient,  the  whole  of  the>  diseased 
pylorus  has  been  removed,  and  the  divided  ends 
of  the  stomach  and  duodenum  united  by^  sutures. 
The  situation  of  the  cancerous  pylorus  within  the 
abdomen  varies  considerably,  as  the  diseased  part 
is  very  apt  to  shift  its  position.  It  is  often  found 
to  have  sunk  down  by  its  weight  to  a  point  below 
the  umbilicus,  and  to  have  contracted  adhesions 
to  adjacent  organs.  The  diseased  part  has  to  be 
isolated  and  the  omental  connexions  of  the  right 
end  of  the  stomach  freely #  divided.  The  vessels 
that  are  almost  certainly  divided  are  the  pyloric, 
the  gastro-epiploica  dextra,  and  the  gastro-duo- 
denal.  The  operation  has  not  been  attended  with 
much  success.  The  cancer  is  apt  to  become  diffuse, 
to  spread  to  adjacent  tissues,  and  to  lead  to  early 
lymphatic  invasion  of  the  greater  and  lesser 
omenta  and  of  the  suprapancreatic  glands. 

Gastrectomy.  —  Considerable  portions  of  the 
stomach  have  been  excised  in  cases  of  cancer,  and 
the  entire  organ  has  been  removed  (total  gastrec- 
tomy) for  the  same  cause.  Up  to  the  time  of 
writing,  some  fifteen  examples  of  this  operation 
have  been  recorded,  with  more  or  less  immediate 
death  in  five.  In  Schlatter's  first  case  of  gas- 
trectomy, performed  in  1897,  the  patient  died  in 
fourteen  months  from  secondary  deposits.  Ricord 
published  a  case  in  which  he  removed  the  whole 
stomach,    the    first    piece   of   the    duodenum,    and 


XVII]  GASTRIC    OPERATIONS  389 

part  of  the  pancreas.  The  patient  was  alive  and 
well  eleven  months  after  the  operation  (Gaz.  des 
Uopitaux,  March  22nd,  1900).  There  is  difficulty 
in  uniting  the  gullet  to  the  small  intestine;  both 
vagi  nerves  are  divided  as  they  emerge  through 
the  diaphragm,  and  the  solar  plexus  is  apt  to  be 
roughly  handled. 

Other  operations  on  the  stomach. — Many  other 
operations  are  performed  upon  the  stomach  which 
call  merely  for  mention  in  this  place.  One  of 
the  most  useful  and  the  most  frequently  per- 
formed is  gastrojejunostomy.  Here  an  opening 
(or  stoma)  is  made  between  the  stomach  and 
the  upper  part  of  the  jejunum.  An  opening 
has  also  to  be  made  in  the  transverse  meso- 
colon in  order  that  the  bowel  may  be  applied 
to  the  posterior  aspect  of  the  stomach.  In  making 
the  opening  the  middle  colic  artery  and  its  larger 
branches  are  to  be  avoided.  The  operation  is  per- 
formed in  cases  of  stenosis  of  the  pylorus,  in 
cases  of  dilatation  of  the  stomach  without  much 
stenosis,  in  certain  examples  of  ulcer,  and  in 
many  other  conditions.  In  the  operation  of 
pyloroplasty,  a  non-malignant  stricture  of  the 
pylorus  is  divided  and  the  pyloric  passage  thus 
made  free.  In  gastroplication  certain  conditions 
of  dilated  stomach  are  dealt  with  by  taking  in  a 
fold  or  pleat  in  the  stomach  wall  and  in  thus 
lessening  its  capacity. 

Small  intestine.*  —  The  average  length  of 
the  small  intestine  in  the  adult  is  22j  feet,  the 
extremes  being  30  feet  and  15  feet,  the  length,  to 
a  considerable  extent,  depending  on  the  degree 
of  contraction  of  the  longitudinal  muscular  coat. 
In  the  foetus,  at  full  term,  the  lesser  bowel  mea- 
sures about  9j  feet.  It  is  roughly  reckoned  that 
the  first  8  or  9  feet  of  the  adult  bowel  belong  to 
the  jejunum,  and  the  remaining  12  or  13  feet  to  the 
ileum.  The  division  into  jejunum  and  ileum  is 
quite  arbitrary.     There  is  no  one  point  where  it 

*  The  account  of  the  intestines  is  based  upon  the  Author's  work  "On 
the  Intestinal  Canal  and  Peritoneum  in  Man."     London,  1885. 


390         THE    ABDOMEN    AND    THE    PELYIS     [Chap. 

can  be  said  that  the  jejunum  ends  and  the  ileum 
commences.  When  the  small  intestines  are  ex- 
posed by  accident  or  operation,  it  is  often  diffi- 
cult, especially  when  there  is  abdominal  disease, 
to  recognize  the  upper  from  the  lower  part  of  the 
gut.  It  may  be  noted,  however,  that  the  jejunum 
is  wider  than  the  ileum  (its  diameter  being  J  of 
an  inch  greater  than  that  of  the  ileum),  and 
its  coats  thicker  and  more  vascular.  If  the  gut 
be  empty,  and  can  be  rendered  translucent  by 
being  held  against  a  light,  the  lines  of  the  valvulse 
conniventes  can  be  well  seen.  These  folds  are 
large  and  numerous  in  the  jejunum,  but  become 
small  and  scanty  in  the  upper  ileum,  and  are 
wanting  in  the  lower  third  of  that  bowel. 

.  The  coils  of  small  intestine  occupy  no  cer- 
tain position  in  the  abdomen.  In  the  foetus,  and 
during  the  earliest  part  of  extra-uterine  life,  the 
bulk  of  the  small  intestine  is  placed  to  the  left 
of  the  middle  line.  This  is  on  account  of  the  re- 
latively large  size  of  the  liver,  to  the  weight  of 
which  the  lesser  bowel  no  doubt  acts  as  a  counter- 
poise. ^  In  the  majority^  of  adult  bodies  the  small 
intestine  is  disposed  in  an  irregularly  curved 
manner  from  left  to  right.  The  gut,  starting 
from  the  duodenum,  will  first  occupy  the  contigu- 
ous parts  of  the  left  side  of  the  epigastric  and 
umbilical  regions;  the  coils  then  fill  some  part  of 
the  left  hypochondriac  and  lumbar  regions;  they 
now  commonly  descend  into  the  pelvis,  reappear 
in  the  left  iliac  quarter,  and  then  occupy  in  order 
the  hypogastric,  lower  umbilical,  right  lumbar, 
and  right  iliac  regions.  Before  reaching  the  latter 
situation  they  commonly  descend  again  into  the 
pelvis. 

Much  interest  attaches  to  the  coils  of  small 
intestine  that  are  found  in  the  pelvis.  These  are 
the  coils  that  are  apt  to  become  involved  and  ad- 
herent in  cases  of  pelvic  peritonitis,  and  that 
would  probably  form  the  protrusion  in  most  cases 
of  obturator,  sciatic,  and  pudendal  hernia.  No 
small    intestine   occupies   the    foetal    pelvis.      The 


XVII]  THE    SMALL    INTESTINE  391 

amount  found  in  the  adult  pelvis  depends  mainly 
upon  the  state  of  distension  of  the  bladder  and 
rectum,  and  upon  the  position  of  the  sigmoid 
flexure.  The  coils  that  are  most  usually  found 
in  this  position  belong  to  the  terminal  part  of  the 
ileum,  and  to  that  part  of  the  intestine  that  has 
been  already  alluded  to  as  possessing  the  longest 
mesentery  (p.  374).  The  ileum  is  the  part  of 
the  intestine  that  is  most  frequently  found  in 
inguinal  and  femoral  hernise.  It  is  also  the  part 
most  usually  involved  in  cases  of  strangulation 
by  internal  bands,  by  holes  in  the  mesentery,  etc. 

Of  all  the  viscera  the  small  intestines  are  the 
most  exposed  to  injury,  and  at  the  same  time  it 
must  be  noted  that  by  their  elasticity,  and  by  the 
ease  with  which  their  coils  slide  over  one  another 
and  so  elude  the  effects  of  pressure,  they  are  the 
best  adapted  to  meet  such  injuries  as  contusions 
and  the  like.  A  minute  punctured  wound  of  the 
small  gut  does  not  lead  to  extravasation  of  con- 
tents. The  muscular  coat  contracts  and  closes  the 
little  opening.  Thus,  in  excessive  tympanites  the 
bowels  are  often  freely  punctured  in  many  places 
with  a  fine  capillary  trocar,  to  allow  the  gas 
to  escape,  without  any  evil  resulting.  A  case  of 
intestinal  obstruction  of  sixteen  weeks'  duration 
is  reported,  in  which  the  abdomen  was  punctured 
150  times  (Boston  Med.  Joum.).  If  the  wound 
be  a  little  larger  the  loose  mucous  membrane  be- 
comes everted  or  protruded  through  the  wound 
and  effectually  plugs  it.  Gross  observed  that  a 
longitudinal^  cut  in  the  small  bowel  2j  lines  in 
length  was  immediately  reduced  to  a  wound  1| 
lines  in  length  by  muscular  contraction,  and  that 
the  eversion  of  the  mucous  membrane  in  addi- 
tion to  this  contraction  entirely  sealed  the  open- 
ing. Even  the  opening  made  in  the  intestine — 
for  example,  in  the  jejunum — by  the  penetration 
of  a  Mauser  bullet  may  be  attended  by  no  escape 
of  contents.  A  contracted  empty  piece  of  bowel 
becomes  nearly  twice  as  long  when  distended. 

Owing   to   the   greater   power   of   the   circular 


392         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

layer  of  muscle  a  longitudinal  wound  gapes  more 
than  a  transverse  wound,  and,  in  consequence  of 
the  greater  muscular  development  of  the  jejunum, 
wounds  of  that  part  gape  more  than  do  those  of 
the  t  ileum.  Transverse  wounds  gape  most  when 
inflicted  across  the  free  border  of  the  gut,  since 
in  that  place  the  longitudinal  muscular  fibres 
are  thickest. 

In  one  remarkable  case  a  man  was  stabbed  in 
the  belly.  It  was  subsequently  found  that  there 
was  a  small  puncture  in  the  ileum,  which  had  been 
plugged  by  the  mucous  membrane  and  further 
secured  by  recent  lymph.  The  man  did  well  until 
the  fourth  day,  when  he  died  somewhat  suddenly. 
It  was  then  found  that  an  intestinal  worm 
(Ascaris  lumbricoides)  had  worked  its  way 
through  the  wound,  breaking  down  the  adhesions, 
and  had  escaped  into  the  peritoneal  cavity.  Ex- 
travasation followed,  and  thus  the  worm  was  the 
immediate  cause  of  the  man's   death. 

The  calibre  of  any  portion  of  the  small  in- 
testine depends  mainly  upon  the  condition  of  its 
muscular  wall.  The  tube  may  become  much  con- 
tracted when  empty.  In  peritonitis  and  in  cer- 
tain other  conditions  the  muscular  coat  is  para- 
lysed and  the  bowel  becomes  intensely  dilated  by 
gas  (tympanites). 

Meckel's  diverticulum. — From  one  to  four  feet 
from  the  end  of  the  ileum  is  sometimes  seen  a 
diverticulum  (Meckel's)  (Fig.  79)  that  represents 
the  remains  of  the  vitello-intestinal  duct  (p.  340). 
It  may  be  expected  in  2  per  cent,  of  the  bodies 
examined.  This  diverticulum  usually  exists  as  a 
tube  of  the  same  structure  as  the  intestine.  Its 
length  varies.  It  may  sometimes  extend  as  a 
patent  tube  as  far  as  the  umbilicus.  It  is  more 
often  but  a  few  inches  long,  and  may  then  end 
in  a  free  conical  or  globular  extremity,  or  in  a 
fibrous  cord.  This  diverticulum  may  cause  in- 
testinal obstruction  in  many  ways.  Its  end  may 
contract  adhesions,  and  beneath  the  bridge  thus 
formed  a  loop  of  bowel  may  be  strangled.     It  may 


XVII] 


MECKEL'S    DIVERTICULUM 


393 


twist  itself  about  a  piece  of  intestine  so  as  to 
form  a  knot  round  it.  It  may,  from  its  adhesions, 
so  drag  upon  the  ileum  as  to  cause  "  kinking  " 
of  the  tube  at  its  point  of  origin.  In  more  than 
one  case  it  has  been  found  in  an  external  hernia. 
It  may  become  invaginated  and  start  an  intussus- 
ception of  the  bowel.  #The  lumen  of  the  gut  is 
often  considerably  diminished  at  or  near  the  site 


Vitelline  Duct- 


M ECKELS    QiVERTIC. 


Fig.  79. — Diagram  to  show  Meckel's  diverticulum,  the  re- 
mains of  the  vitello-intestinal  duct,  and  of  the  artery 
to  the  yolk  sac. 

of  the   diverticulum,   and  at  this   narrowing  in- 
tussusception of  the  bowel  may  commence. 

A  loop  of  bowel  may  be  strangulated  over 
the  remains  of  a  patent  vitello-intestinal  duct 
(Fig.  79).  The  duct,  if  complete,  ends  at  the 
umbilicus.  The  artery  of  the  yolk  sac  may  also 
persist,  ^and  form  a  cord  between  the  mesentery 
of  the  ileum  and  the  umbilicus,  and  over  this 
a  loop  of  bowel  may  become  strangulated.  A 
short  cord  may  pass  from  the  mesentery  of  the 
ileum  to  the  fundus  of  the  diverticulum,  and 
between  this  and  the   diverticulum  a  knuckle  of 


394         THE    ABDOMEN    AND    THE    PELVIS     [Chap 

bowel  may  become  incarcerated.  Such  a  cord  may 
arise  in  three  ways  :  (1)  from  the  proximal  part 
of  the  artery  of  the  yolk  sac,  (2)  from  the  free 
border  of  a  mesentery  with  which  the  diverti- 
culum may  be  provided,  and  (3)  by  the  elongation 
of  an  inflammatory  adhesion  between  the  apex  of 
the  diverticulum  and  the  mesentery  (Fig.  79). 

Duodenum  and  fossa  duodeno  =  jejunalis,— 
The  first  portion  of  the  duodenum  is  nearly 
horizontal.  It  measures  about  2  inches  in 
length  and  passes  backwards  from  the  pylorus  to 
near  the  upper  end  of  the  right  kidney.  The 
second  portion,  about  3  inches  in  length,  descends 
vertically  in  front  of  the  inner  border  of  the 
right  kidney  to  the  level  of  the  third  lumbar 
vertebra.  The  third  portion,  some  5  inches  in 
length,  crosses  from  right  to  left  in  front  of  the 
third  vertebra,  and  then  ascends  for  a  short  dis- 
tance on  the  surface  of  the  left  psoas  muscle,  to 
end  in  the  jejunum  to  the  left  of  the  second 
lumbar  vertebra  (Fig.  75,  p.  376).  The  first  por- 
tion, which  is  movable,  is  invested  by  peritoneum 
in  the  same  manner  as  the  stomach.  The  second 
part  is  covered  by  peritoneum  in  front  only,  ex- 
cept at  the  spot  where  it  is  crossed  by  the  trans- 
verse colon.  The  third  part  is  also  covered  by 
peritoneum  on  its  anterior  aspect  only,  this  mem- 
brane being,  however,  free  of  the  gut  where  the 
superior  mesenteric  vessels  cross  it.  A  constric- 
tion, probably  functional  in  nature,  is  usually 
found  at  the  termination  of  the  third  stage. 

The  end  of  the  duodenum,  the  duodeno- 
jejunal bend,  is  very  firmly  held  in  place  by  a 
band  of  fibro-muscular  tissue  that  descends  upon 
it  from  the  right  crus  of  the  diaphragm  and  the 
tissue  about  the  cceliac  axis.  This  band  is  called 
the  suspensory  muscle  of  the  duodenum  (Treitz).  It 
serves  also  to  support  the  mesentery.  In  ptosis  of 
the  viscera  the  neck  of  the  pancreas  and  duodeno- 
jejunal bend  are  the  least  displaced^  parts  be- 
cause of  their  attachment  to  the  posterior  wall  by 
the  fibrous  tissue  round  the  cceliac  axis  and  origin 


XVII]  BRUNNER'S    GLANDS  395 

of  the  superior  mesenteric  artery.  All  sections  of 
the  duodenum  have  been  ruptured  by  violence. 
Owing  to  its  large  non-peritoneal  surface,  the 
bowel,  if  approached  from  behind,  may  be 
wounded   without   opening   the   peritoneum. 

Brunner's  glands  occur  in  the  first  stage  of  the 
duodenum;  their  secretion  probably  protects  this 
part  of  the  gut  against  the  acid  chyme  which 
is  only  neutralized  as  it  reaches  the  second  stage. 
It  is  probably  because  of  the  nature  of  its  con- 
tents that  the  first  stage  of  the  duodenum  is  so 
frequently  the  site  of  ulceration ;  over  90  per  cent, 
of  duodenal  ulcers  occur  in  the  first  stage  (Collin). 
The  ulcer  may  perforate  and  the  contents  escape 
into  the  subhepatic  space,  or  adhesions  may  form 
to  surrounding  organs — the  gall-bladder,  the  liver, 
the  head  of  the  pancreas,  the  right  kidney,  or  the 
hepatic  flexure  of  the  colon. 

Very  frequently  small  diverticula  of  the  mu- 
cous membrane  are  formed  at  the  point  where 
the  common  bile  -  duct  perforates  the  muscle 
coat  of  the  duodenum.  They  are  often  large 
enough  to  take  the  first  joint  of  the  forefinger, 
and  occur  especially  in  cases  of  ptosis  of  the 
viscera.  In  the  newly  born  a  complete  occlusion 
of  the  duodenum  may  be  found  just  above  the 
entrance  of  the  common  bile-duct. 

Passing  from  the  front  of  the  terminal  (as- 
cending) part  of  the  duodenum,  a  fold  of  peri- 
toneum is  often  seen,  that  joins  the  parietal 
peritoneum  to  the  left  of  the  piece  of  gut  in  ques- 
tion. This  fold  marks  off  a  fossa  of  triangular 
outline,  the  orifice  of  which  is  directed  upwards. 
I  have  found  the  fossa  in  about  50  per  cent, 
of  the  bodies  examined.  It  is  called  the  fossa 
duodeno=jejunalis;  it  is  usually  large  enough  to 
lodge  the  tip  of  the  finger,  and  its  opening  lies 
just  below  the  duodeno-jejunal  bend  (Fig.  80). 
Besides  the  lower  fold,  there  is  often  also 
an  upper,  so  that  the  fossa^  is  bounded  both 
above  and  below  by  a  crescentic  margin.  In  the 
natural    state    of    parts,    the    fossa   is    filled   by 


396 


THE    ABDOMEN    AND    THE    PELVIS    [Chap. 


the  terminal  part  of  the  duodenum;  the  fossa 
is  only  apparent  when  the  duodenum  is  arti- 
ficially displaced.  The  inferior  mesenteric  vein 
ascends  near  the  left  margin  of  the  pocket. 
This  fossa  is  the  anatomical  cause  of  mesen- 
teric, mesocolic,  mesogastric,  or  retroperitoneal 
hernia.  The  commencement  of  the  jejunum  presses 
into  the  fossa,  enlarges  its  cavity,  and  ultimately 


'InJeHo  r\m  esefi  ter[ic  ^ 


DUODENAL  FOLD 


Fig.  80. — The  fossa  duodeno-jejunalis. 


separates  the  peritoneum  from  its  posterior  at- 
tachments. More  and  more  of  the  small  intestine 
passes  into  the  increasing  pouch,  until  at  last,  as 
in  the  case  reported  by  Sir  Astley  Cooper  and  in 
many  others,  nearly  the  whole  of  the  small  intes- 
tine may  be  found  lodged  in  an  enormous  median 
retroperitoneal  sac,  the  mouth  of  which  is  the 
orifice  of  the  fossa  duodeno-jejunalis.  The  duo- 
denum can  be  seen  to  enter  the  sac  and  the  end 
of  the  ileum  to  leave  it.     The  sac  usually  extends 


XVII]    OPERATIONS    ON    SMALL    INTESTINE       397 

downwards  on  the  left  side,  and  may  reach  the 
promontory  of  the  sacrum.  These  hernise  vary  in 
size,  but  are  as  a  rule  large.  The  csecum  and 
ascending  colon  have  their  normal  position,  but 
the  transverse  and  descending  parts  of  the  colon 
are  stretched  over  and  displaced  by  the  sac.  The 
renal  artery  is  behind  the  hernia,  and  the  in- 
ferior mesenteric  artery  is  in  front  of  it  and  to 
the  left.  A  branch  of  this  vessel,  the  colica  sinis- 
tra, is  near  to  the  orifice  of  the  sac  in  its  lower 
part.  Numerous  modifications  occur  in  the  form 
and  boundaries  of  this  peritoneal  fossa,  and  a 
hernia  may  enlarge  in  any  direction,  but  usually 
towards  the  left,  where  it  passes  behind  the  left 
margin  of  the  fossa  containing  the  inferior 
mesenteric  vein. 

Operations  on  the  small  intestine. — Enterotomy 
is  the  operation  of  opening  the  small  intestine 
above  some  obstruction  that  threatens  to  be  fatal 
or  insuperable.  A  knuckle  of  bowel,  above  the 
obstruction,  is  secured  to  the  wound  in  the  ab- 
dominal wall,  and  opened.  The  small  intestine 
has  also  been  opened  to  remove  impacted  foreign 
bodies  and  large  gall-stones.  In  such  cases  the 
intestinal  wound  is  closed  immediately. 

F uterectomy. — Parts  of  the  small  intestine  have 
been  >  resected  with  success  for  various  diseased 
conditions^  In  one  case  more  than  two  yards  of 
the  small  intestine  were  cut  away  on  account  of 
multiple  stricture.  The  patient,  a  young  woman, 
made  an  excellent  recovery.  Resections  have  also 
been  successfully  performed  in  cases  of  bullet 
wound  or  stab  involving  the  lesser  bowel,  and  in 
other  injuries.  Tumours  of  the  gut  have  been 
removed  by  a  partial  resection.  Non-malignant 
strictures  of  the  bowel  have  been  treated  by  in- 
cision and  dilatation. 

The  bowel  above  an  obstruction  has  been  con- 
nected to  the  bowel  below  an  obstruction  by  the 
operation  called  intestinal  anastomosis  or  short- 
circuiting. 

Experience  shows  that  if  leakage  occurs  after 


398         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

resection  or  suture  of  intestine  it  will  most  likely 
occur  along  the  attachment  of  the  mesentery. 
This  circumstance  is  thus  explained  by  Mr.  An- 
derson :  The  two  layers  of  the  mesentery  diverge 
as  they  approach  the  bowel,  and  so  leave  a  tri- 
angular space,  the  base  of  which,  averaging  about 
■^ths  of  an  inch  in  width,  is  formed  by  the  un- 
covered muscular  tissue.  It  is  the  existence  of 
this  bare  piece  of  intestine  that  renders  adjust- 
ment of  the  serous  coat  at  the  attachment  of  the 
mesentery  a  matter  of  some  difficulty. 

Heo-csecal  region. — The  caecum  is,  to  a  cer- 
tain extent,  rudimentary  m  in  man,  as  it  is  also 
in  the  carnivora.  In  herbivorous  animals  it  is  of 
great  size,  and  appears  to  serve  as  a  reservoir  for 
the  elaboration  and  absorption  of  food.  It  has 
been  said  that  the  caecum  in  man  exists  as  an 
anatomical  protest  against  vegetarianism.  The 
appendix  persists  as  the  remains  of  the  larger 
caecum  of  lower  mammals.  In  the  human  foetus 
it  can  be  seen  to  be  but  the  narrowed  ex- 
tremity of  a  capacious  caecum.  The  foetal  type 
of  caecum,  which  is  very  characteristic,  may  per- 
sist throughout  life.  <  From  the  point  of  view  of 
evolution  the  appendix  would  appear  to  be  becom- 
ing obliterated.  Like  other  functionless  parts 
that  persist  as  developmental  relics,  it  is  very  fre- 
quently the  seat  of  disease,  and  it  is  worthy  of 
note  that  such  disease  tends  to  cause  the  entire 
obliteration  of  the  part  (as  after  many  forms  of 
so-called  appendicitis). 

It  must  be  understood  that  the  term  ccecum  is 
applied  to  that  part  of  the  colon  which  lies  below 
the  entrance  of  the  ileum.  The  average  breadth 
of  the  adult  caecum  is  3  inches,  its  average  length 
(vertical  measurement)  2j  inches.  These  measure- 
ments apply  to  the  organ  as  seen  in  the-  cadaver ; 
in  the  living  it  is  constantly  changing  its  shape 
according  to  its  state  of  physiological  activity. 
The  caecum  normally  contains  gas,  and  gives  a 
high,  tympanitic  note  on^  percussion ;  Glenard 
found  that  in  cases  of  ptosis  of  the  viscera  it  was 


XVII] 


ILEO-CiECAL    REGION 


399 


often    contracted,    and    when    palpated    had    the 
consistency  of  a  sausage.  .  . 

The  caecum  is  usually  lodged  in  the  right  iliac 
fossa,  and  is  so  placed  that  its  apex  corresponds 
with  a  point  a  little  to  the  inner  side  of  the 
middle  of  Poupart's  ligament.  When  distended 
with  gas  or  faecal  contents  it  occupies  the  whole 
of  the  right  iliac  fossa.  The  ileo-caecal  orifice  is 
situated    immediately    below    the    spino-umbilical 


ILEOCOLIC  FOSSA 


BLOODLESS  FOLD 


ILEO-CWBCAL  F036A 

Fig.  81.— The  peritoneal  fossee  of  the  ileo-caecal  region. 

line  and  externally  to  Monro's  point  (see  Fig.  75, 
p.   376). 

A  slightly  distended  caecum  so  located  may  be 
emptied  by  flexing  the  thigh  upon  the  abdomen. 
The  caecum  is  always  entirely  invested  by  peri- 
toneum. Its  posterior  surface  is  never  in  con- 
nexion with  the  areolar  tissue  of  the  iliac  fossa. 
The  peritoneum  is  reflected  from  the  commence- 
ment of  the  ascending  colon  on  to  the  posterior 
parietes  below  the  level  of  the  iliac  crest.  A 
mobile  caecum  may  hang  over  the  pelvic  brim,  or 
occupy  the  pelvis,  or  even  find  its  way  into  an 
inguinal  hernia  of  the  left  side.  The  caecum  is 
not  infrequently  found  in  an  inguinal  or  femoral 
hernia  of  the  right  side  (caecal  hernia).  Such  herniae 
are,  except  in  a  few  rare  instances,  provided  with 


400         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

a  proper  and  complete  peritoneal  sac.  Foreign 
bodies  that~  have  been  swallowed  are  very  apt  to 
lodge  in  the  caecum,  and  in  that  situation  may 
cause  ulceration  and  even  perforation  of  the 
bowel,  producing  one  form  of  typhlitis.  In  cases 
of  faecal  retention,  also,  the  largest  accumulation 
of  faecal  matter  is  very  usually  met  with  in  the 
caecum,^  and  upon  that  part  of  the  bowel  when 
distension  is  extreme  the  greatest  strain  usually 
comes.  Stercoral  ulcers  (ulcers  due  to  the  pres- 
sure and  irritation  of  retained  faeces)  are  more 
often  met  with  in  the  caecum  than  in  any  other 
part  of  the  colon.  Solitary  follicles  are  numerous 
in  the  mucous  membrane  of  the  caecum,  especially 
near  the  ileo-caecal  orifice.  Intestinal  concretions 
also  are  not  uncommon  in  this  part. 

Three  kinds  of  movement  occur  in  the  caecum  : 
(1)  a  churning  movement,  which  has  been  ob- 
served to  commence  within  an  hour  of  taking 
food;  (2)  antiperistaltic  movements,  which  begin 
in  the  colon  and  end  in  the  caecum;  (3)  pro- 
pulsive or  emptying  movements.  Water  is  ab- 
sorbed, and  the  faeces  commence  to  assume  a  solid 
consistency  as  they  reach  the  transverse  colon. 
The  ileo-caecal  orifice  is  guarded  by  a  muscular 
sphincter  (ileo-ccecal  sphincter) ;  it  is  innervated 
by  the  sympathetic  system  and  regulates  the 
escape  of  chyme  from  the  ileum  (Elliot  and  B. 
Smith) :  Sir  William  Macewen  has  seen  it  in 
action  in  the  case  of  a  soldier  in  whom  a  wide 
caecal  fistula  resulted  from  a  gunshot  injury.  The 
same  observer  has  also  seen  a  secretion  escaping 
from  the  mouth  of  the  appendix,  which  is  situated 
about  1  inch  below  the  ileo-caecal  orifice. 

The  appendix  varies  in  length.  Its  average 
measurement  in  the  adult  is  4  inches,  the  extremes 
being  1  inch  and  6  inches.  Its  position  varies, 
although,  as  a  rule,  it  is  seen  to  lie  behind  the 
nnd  of  the  ileum  and  its  mesentery,  and  to  point 
in  the  direction  of  the  spleen.  It  frequently  also 
lies  behind  the  caecum.  I  have  seen  the  appendix 
so  placed  with  reference  to  the  bowel  that  it  would 


XVII]  THE    APPENDIX  401 

have  been  encountered  in  a  right  lumbar  colotomy. 
In  such  cases  the  appendix  has  been  pushed  be- 
hind the  caecum  and  caught  in  the  mesocolon 
during  the  later  months  of  foetal  life,  when  the 
colon  migrates  from  the  neighbourhood  of  the 
liver  to  the  right  iliac  fossa.^  The  appendix  may 
hang  within  the  pelvis  and,  in  inflammatory  con- 
ditions, contract  adhesions  to  the  ovary  or  other 
pelvic  structures.  I  have  found  an  inflamed  ap- 
pendix adherent  to  the  liver,  and  another  in  the 
left  iliac  fossa.  It  has  found  its  way  down  both 
the  right  and  the  left  inguinal  canals. 

The  tip  of  the  process  may  adhere  to  a  neigh- 
bouring peritoneal  surface,  and  thus  form  a 
44  band,"  beneath  which  a  piece  of  small  intestine 
may  be  strangulated. 

The  mesentery  of  the  appendix  (Fig.  81),  which 
contains  an  artery  derived  from  the  ileo-colic, 
may  be  so  short  as  to  produce  obstructive  kinks 
in  the  appendix.  The  mucous  lining  is  so  crowded 
with  solitary  lymphoid  follicles  as  almost  to  oc- 
clude its  lumen.  Like  other  lymphoid  structures 
these^  follicles  begin  to  atrophy  soon  after  adult 
life  is  reached.  In  some  forms  of  appendicitis 
these  follicles  are  involved. 

Lymphatics  of  the  caecum  and  appendix 
(Fig.  82). — Since  in  inflammation  of  the  appendix 
infection  spreads  chiefly  by  its  lymphatics,  the 
arrangement  of  this  system  is  of  surgical  im- 
portance. As  in  other  parts  of  the  alimentary 
canal,  there  are  three  plexuses  of  lymphatics  : 
(1)  a  submucous,  which  receives  the  lymph  from 
the  mucous  membrane ;  (2)  an  intermuscular 
plexus;  (3)  a  subserous  plexus.  All  three  are  in 
the  freest  communication.  The  lymphoid  follicles 
are  situated  in  the  submucous  plexus;  at  breaks 
of  the  muscular  coat  the  submucous  and  subserous 
plexuses  are  in  direct  continuity;  hence  infection 
may  readily  spread  to  the  peritoneal  coat,  setting 
up  peritonitis.  The  efferent  vessels  pass  chiefly 
into  the  meso-appendix,  where  one  or  more  glands 
may  occur,  but  most  of  the  efferent  vessels  pass 


402 


THE    ABDOMEN    AND    THE    PELVIS    [Chap. 


to  the  ileo-colic  group  of  glands  situated  in  the 
ileo-colic  angle  (Fig.  82).  This  group  also  receives 
lymphatics  from  the  anterior  part  of  the  caecum 
and  base  of  the  appendix  by  vessels  which  pass 
through  the  anterior  colic  fold.  Vessels  from  the 
posterior  aspect  of  the  caecum  also  join  the  ileo- 
colic group.  These  vessels  do  not  communicate 
with  the  lymphatics  of  the  iliac  or  lumbar  regions 
(Jamieson  and  Dobson).     The  vessels  which  issue 


Ileo-Colic  Vessels 


Ascend.  Colon 


Mesentery  of  Appendix 


Fig.  82. — The  course  of   the   lymphatics   of   the  caecum, 
appendix,  and  colon.       (After  Jamieson  and  Dobson. ) 


from  the  ileo-colic  group  of  glands  join  the  efferent 
vessels  of  the  small  intestine  and  of  the  ascending 
colon,  and  enter  glands  situated  along  the  superior 
mesenteric  artery. 

It  is  in  the  ileo-caecal  region  that  intussuscep- 
tion  most  frequently  occurs.  In  this  condition 
one  part  of  the  intestine  is  prolapsed  or  "tele- 
scoped "  into  the  lumen  of  an  immediately  adjoin- 
ing part.  In  the  ileo-caecal  variety  (the  common- 
est form)  the  narrow  ileum,  and  subsequently  the 
caecum,   are  prolapsed  into  the  colon.     The  ileo- 


XVII]         BATE    OF    PROGRESS    OF    FOOD  403 

caecal  orifice  forms  the  summit  of  the  protrusion 
or  intussusceptum.  In  the  ileo-colic  variety  (the 
rare  form)  the  end  of  the  ileum  is  prolapsed 
through  the  valve.  The  orifice  and  the  caecum 
remain  in  their  normal  situations,  and  the  sum- 
mit of  the  intussusceptum  is  formed  only  by  the 
ileum.  In  another  variety,  which  is  also  common, 
the  apex  of  the  intussusceptum  is  formed  by  the 
fundus  of  the   invaginated  csecum. 

There  are  three  fairly  constant  peritoneal 
fossae,  which  are  sometimes  the  seat  of  hernia,  in 
the  ileo-caecal  region  (Fig.  81).  They  are  (1)  the 
ileo-colic,  situated  between  the  ascending  colon 
and  termination  of  the  ileum;  a  fold  containing 
the  anterior  caecal  artery  bounds  it^ above;  (2)  the 
ileo-caecal  fossa,  between  the  termination  of  the 
ileum  and  the  caecum;  it  is  bounded  in  front  by 
the  bloodless  fold  and  behind  by  the  mesentery 
of  the  appendix;  (3)  the  retrocaecal  fossa,  behind 
the  caecum ;  it  is  bounded  on  the  right  by  the  lower 
termination  of  the  ascending  mesocolon. 

Rate  at  which  the  contents  of  the 
alimentary  canal  progress. — A  study  of  the 
movements  of  a  bismuth-laden  diet  along  the 
alimentary  canal  of  the  living  materially  modifies 
the  conception  one  forms  of  the  bowel  from  an 
examination  of  this  part  in  the  dead.  The  account 
given  here  is  founded  chiefly  on  the  observations 
of  Dr.  A.  F.  Hertz.  The  contents  of  the  stomaeh 
begin  to  pass  into  the  duodenum  very  soon  after 
food  is  taken ;  in  4j  hours  the  food  begins  to 
enter  the  caecum,  which  gradually  fills.  In  6 J 
hours  the^  bismuth-laden  contents  have  reached 
the  hepatic  flexure,  and  in  9  hours  the  splenic 
flexure.  In  the  ascending  colon  and  first  part  of 
the  transverse  colon  the  fluid  part  of  the  faeces 
is^  absorbed.  The  progress  along  the  descending 
iliac  and  pelvic  colon  is  slow.  In  30  hours  the 
bismuth  diet  is  lodged  in  the  iliac  and  pelvic 
colons.  Although  faeces  are  t  occasionally  lodged 
in  the  rectum,  in  the  majority  of  people  this  is 
only    the    case     during    defaecation.      The   colon 


404         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

must  be  regarded  not  as  a  passive  tube,  but  as 
an  active  muscular  organ  concerned  in  propulsion 
as  well  as  absorption. 

JLarge  intestine. — From  the  csecum  to  the 
sigmoid  flexure,  this  portion  of  the  bowel  is 
accessible  to  pressure  except  at  the  hepatic  and 
splenic  flexures,  which  are  deeply  placed.  The 
hepatic  flexure  is  under  the  shadow  of  the  liver, 
and  the  splenic  curve,  which  reaches  a  higher 
level,  is  behind  the  stomach  (Fig.  75,  p.  376).  The 
position  of  the  transverse  colon  can  often  be  well 
marked  out.  It  crosses  the  belly  transversely,  so 
that  its  lower  border  is  nearly  on  a  level  with 
the  umbilicus  (Fig.  75).  In  cases  of  faecal  accu- 
mulation, the  outline  of  the  colon,  with  the 
exception  of  the  two  flexures  above  named,  may 
be  distinctly  defined.  In  distensions  of  the  small 
intestine  the  belly  tends  to  present  the  greatest 
degree  of  swelling  in  front,  and  about  and  below 
the  navel.  In  distension  of  the  larger  gut,  the 
front  of  the  abdomen  may  remain  (for  a  while  at 
least)  comparatively  flat,  while  the  distension  will 
be  most  obvious  in  the  two  flanks  and  in  the 
region  just  above  the  umbilicus.  Tumours  of  the 
transverse  colon,  and  of  the  lower  two-thirds  of 
the  ascending  and  descending  colon,  can  be  well 
defined,  even  when  of  moderate  size,  and  in  cases 
of  intussusception  the  progress  of  the  mass  along 
the  colon  can  often  be  traced  with  great  ease,  and 
the  effects  of  enemata  and  other  methods  of  re- 
duction carefully  watched.  The  diameter  of  the 
large  intestine  (excluding  the  rectum)  gradually 
diminishes  from  the  csecum  to  the  sigmoid  flexure, 
the  diameter  of  the  former  being  about  2j  inches, 
of  the  latter  lj  inches.  The  narrowest  part  of  this 
segment  of  the  bowel  is  at  the  point  of  junction 
of  the  sigmoid  flexure  with  the  rectum,  and  it 
is  significant  that  this  is  the  point  at  which 
stricture  is  the  most  common. 

The  tendency  to  stricture  increases  as  one  pro- 
ceeds downwards  from  the  csecum  to  the  anus.  A 
stricture  is  frequent  in  the  descending  colon,  less 


XVII]  LAEGE    INTESTINE  405 

frequent  in  the  transverse  colon,  while  in  the 
ascending  colon  it  is  comparatively  rare.  Stric- 
tures are  not  uncommon  about  the  flexures  of  the 
bowels.* 

The  ascending  and  the  descending  colon  are 
placed  vertically.  The  average  length  of  the  as- 
cending colon  in  the  adult  (as  measured  from  the 
tip  of  the  caecum  to  the  hepatic  flexure)  is  8  inches. 
The  average  length  of  the  descending  colon  (from 
the  splenic  bend  to  the  commencement  of  the  sig- 
moid flexure)  is  8j  inches.  The  descending  colon 
is  very  little  liable  to  variation,  and  is  always 
found  in  a  semi-contracted  condition.  That  part 
of  the  descending  colon  which  lies  in  the  left 
iliac  fossa,  from  the  iliac  crest  to  the  left  psoas 
muscle,  is  now  distinguished  as  the  iliac  colon. 
In  cases  of  non-descent  of  the  caecum  the  ascend- 
ing colon  may  be  absent  (p.  401).  I  have 
pointed  out  that  in  52  per  cent,  of  adult  bodies 
there  is  neither  an  ascending  nor  a  descending 
mesocolon,  and  that  a  mesocolon  may  be  expected 
on  the  left  side  in  36  per  cent,  of  all  cases,  and 
on  the  right  side  in  26  per  cent.  These  points 
are  of  importance  in  connexion  with  the  some- 
what uncommon  operation  of  lumbar  colotomy. 
The  breadth  of  the  mesocolon,  when  it  exists, 
varies  from  1  to  3  inches.  The  line  of  attach- 
ment of  the  left  mesocolon  is  usually^  along  the 
outer  border  of  the  kidney,  and  is  vertical.  That 
of  the  right  mesocolon  is,  as  a  rule,  less  vertical, 
runs  along  the  outer  border  of  the  kidney,  and 
crosses  its  lower  end  obliquely  from  right  to  left. 

The  transverse  colon  has  an  average  measure- 
ment of  20  inches.  It  is  not  quite  horizontal, 
since  the  splenic  flexure  is  on  a  higher  level  than 
the  hepatic  flexure,  as  well  as  posterior  to  it,  and 
always  shows  a  number  of  bends,  one  occurring 
near  its  commencement  and  another  near  its  end. 
Faecal  masses  lodged  in  the  transverse  colon  have 
given  rise  to  many  errors  in  diagnosis.     In  some 

?  See  "Intestinal  Obstruction,"  by  the  Author.    London,  1899. 


406         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

instances  this  part  of  the  colon  is  displaced  to- 
wards the  pelvis,  so  that  V  or  U-shaped  bends 
are  produced.  In  such  cases  the  point  of  the  V 
or  U  may  reach  the  symphysis  pubis,  while  the 
two  colic  flexures  occupy  their  proper  situations. 
These  deviations  are  described  in  detail  in  my 
work  on  Intestinal  Obstruction.  The  sagging  and 
elongation  of  the  transverse  colon  indicate  a  loss 
of  tone  and  of  contraction  in  its  muscular  coat, 
especially  of  the  longitudinal  taeniae.  There  is 
a  corresponding  relaxation  in  the  muscular  walls 
of  the  abdomen,  so  that  the  normal  support  is 
withdrawn  from  the  abdominal  viscera.  The 
peritoneal  supports  of  the  hepatic  and  splenic 
flexure  become  stretched  and  appear  to  compress 
and  obstruct  the  free  passage  of  the  colic  contents. 
The  constipation  in  such  cases  appears  to  be  due, 
not  to  the  kinking  and  compression  of  the  colon, 
but  to  the  primary  relaxation  of  the  colic  mus- 
culature, the  cause  of  which  is  still  obscure. 

The  right-hand  part  of  the  transverse  colon 
is  in  intimate  relation  with  the  gall-bladder,  and 
is  commonly  found  to  be  bile-stained  after  death. 
In  some  cases  where  gall-stones  have  been  lodged 
within  the  gall-bladder,  the  walls  of  that  struc- 
ture have  ulcerated  from  pressure,  the  ulceration 
has  involved  the  subjacent  transverse  colon,  and 
thus  a  fistula  has  been  established  between  the 
gall-bladder  and  the  gut,  through  which  large 
stones  have  been  passed.  Hepatic  abscesses  also 
have  discharged  themselves  through  the  trans- 
verse^  colon.  The  transverse  colon  often  finds  its 
way  into  an  umbilical  hernia,  and  has  been  found 
to  be  concerned  in  many  of  the  cases  of  hernia  into 
the  foramen  of  Winslow. 

The  sigmoid  flexure.  —  The  segments  of  gut 
termed  the  sigmoid  flexure  and  "  the  first  part  of 
the  rectum  "  form  together  a  single  simple  loop 
that  cannot  be  divided  into  parts.  This  loop 
begins  where  the  iliac  colon  ends,  and  ends  at 
the  commencement  of  the  so-called  "  second  part 
of  the  rectum  " ;  at  a  spot,  in  fact,  where  the  meso- 


XVII]  SIGMOID    FLEXURE  407 

rectum  ceases,  opposite  about  the  third  piece  of 
the  sacrum.  This  loop,  when  unfolded,  describes 
a  figure  that,  if  it  must  be  compared  to  a  letter, 
resembles  the  capital  Omega  fl.  It  may  well  be 
termed  the  Omega  loop,  and  the  term  rectum  be 
limited  to  the  short  piece  of  practically  straight 
gut  that  is  now  described  as  the  second  and  third 
parts  of  the  rectum.  By  the  majority  of  anato- 
mists and  surgeons  the  Omega  loop  is  now  named 
the  "  pelvic  colon, ;;  although  at  birth  and  fre- 
quently in  the  adult  it  is  not  pelvic  in  position. 
The  average  length  of  the  loop  in  the  adult  is 
17|  inches.  The  two  extremities  of  the  loop  are 
about  3  or  4  inches  apart.  If  they  are  approxi- 
mated to  one  another,  as  by  contracting  peri- 
tonitis at  the  root  of  the  sigmoid  mesocolon,  a 
kind  of  pedicle  is  established,  about  which  the 
loop  may  readily  become  twisted.  Such  a  twist 
of  the  bowel  constitutes  a  volvulus  of  the  sigmoid 
flexure ;  and  it  may  be  here  said  that  volvulus 
of  the  intestine  is  more  commonly  met  with  in  this 
loop  than  in  any  other  part  of  the  canal. 

The  line  of  attachment  of  the  mesocolon  of  the 
Omega  loop  (the  sigmoid  mesocolon)  crosses  the 
left  psoas  muscle  and  the  iliac  vessels  near  their 
bifurcation ;  it  then  turns  abruptly  down,  and 
running  nearly  vertical,  terminates  at  the  middle 
line. 

In  the  left  wall  of  this  mesocolon,  close  to  the 
point  where  it  lies  over  the  iliac  vessels,  a  fossa 
is  sometimes  to  be  found.  It  is  produced  by  the 
sigmoid  artery,  and  is  about  lj  inches  in  depth. 
It  is  called  the  intersigmoid  fossa,  and  is  the 
seat  of  sigmoid  hernia  (Fig.  83,  mc).  Two  cases 
of  strangulated  hernia  in  this  fossa  have  been 
recorded. 

The  sigmoid  flexure,  or  Omega  loop,  when 
empty,  normally  occupies  the  pelvis.  When  dis- 
tended this  piece  of  bowel  may  become  so  enor- 
mously dilated  as  to  reach  the  liver.  The  chief 
examples  of  extraordinary  dilatation  of  the 
colon  concern  this  loop.     Fsecal  masses  are  very 


408 


THE    ABDOMEN    AND    THE    PELVIS     [Chap. 


frequently  lodged  in  the  free  end  of  the  loop,  and 
certain  intestinal  concretions  have  been  met  with 
in  the  same  situation. 

I  have  shown  by  experiment  that  the  "  long 
tube,"  when  introduced  through  the  anus,  cannot 


Fig.   83. — Sigmoid   flexure    turned   upwards    to   show    the 
intersigmoid  fossa.     \(Jonnesco.) 

S.  F,  Sigmoid  flexure  ;  as,  sigmoid  artery  ;  MC,  mesosigmoid  fossa  ; 
a  e,  external  iliac  artery  ;  u,  ureter  in  front  of  internal  iliac 
vessels. 


be  passed  beyond  the  sigmoid  flexure  in  ordinary 
cases  and  with  a  normal  disposition  of  the  bowel. 

In  cases  of  congenital  absence  or  deficiency 
of  the  rectum,  the  sigmoid  flexure  is  often  opened 
in  the  groin  and  an  artificial  anus  established 
there.  This  operation,  known  as  Littre's  opera- 
tion, is,  it  must  be  confessed,  not  very  successful. 


XVII]  ii  LABGE    INTESTINE  409 

One  difficulty  has  been  said  to  depend  upon  the 
uncertain  position  of  the  sigmoid  flexure  in  cases 
of  congenital  deformity,  it  being  sometimes  on  the 
right  side  a^id  sometimes  in  the  pelvis  at  the 
middle  line.  It  is  rarely,  however,  found  in  these 
positions.  Out  of  100  post-mortem  examinations 
on  young  infants,  Curling  found  the  loop  on  the 
left  side  in  eighty-five  cases.  Out  of  ten  children 
who  were  operated  on  for  imperforate  anus,  the 
loop  was  found  in  the  left  fossa  in  only  one  case 
(Montgomery). 

The  iliac  and  pelvic  colons  are  often  the 
seat  of  multiple  diverticula  of  the  mucous  coat. 
These  diverticula  occur  at  points  where  vessels 
enter  or  emerge  from  the  bowel,  thus  giving  rise 
to  weak  points  in  the  muscular  coat  through 
which  the  mucous  coat  forms  small  hernias  or 
diverticula.  They  protrude  within  the  appen- 
dices epiploicse  and  root  of  the  mesentery.  This 
part  of  the  colon  serves  as  a  receptaculum  for 
the  faeces,  and  is  always  tonically  contracted, 
and  this  is  probably  the  reason  why  the  pelvic 
colon  is  more  frequently  the  seat  of  these  diver- 
ticula than  any  other  part  of  the  bowel. 

The  section  of  the  body  shown  in  Fig.  84  gives 
the  immediate  relations  of  the  descending  colon, 
and  the  structures  to  be^  cut  through  if  the  sur- 
geon wishes  to  expose  this  structure  in  the  loins. 
The  position  of  the  descending  colon  in  the  loin 
may  be  represented  by  a  line  drawn  vertically 
upwards  from  a  point  on  the  iliac  crest  1  inch 
external  to  the  outer  border  of  the  erector  spinse. 
An  incision  is  made  across  the  centre  of  this  line 
parallel  to  the  last  rib,  and  so  planned  that  the 
centre  of  the  incision  corresponds  to  the  centre  of 
the  line.  The  superficial  tissues  having  been  in- 
cised, the  following  structures  are  divided  in 
layers  in  the  order  here  given  (Fig.  84)  :  (1)  The 
latissimus  dorsi  and  external  oblique  muscles  to 
an  equal  extent ;  (2)  the  internal  oblique  in  the 
entire  length  of  the  incision ;  (3)  the  fascia  lum  • 
borum,    with  a   few  of  the  most  posterior  fibres 


410         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

of  the  transversalis  muscle;  (4)  the  transversalis 
fascia.  The  quadratus  lumborum  will  be  exposed 
in  the  posterior  inch  or  so  of  the  incision,  and 


Fig.  84. — Horizontal  section  through  the  body  at  the  level 
of  the  umbilicus.      {After  Braune.) 

a,  Spine  of  the  fourth  lumbar  vertebra  ;  b,  disc  between  third  and 
fourth  vertebrae  ;  c,  umbilicus  ;  d,  quadratus  lumborum  ;  e,  psoas  ; 
/,  external  oblique,  with  internal  oblique  and  transversalis 
muscles  beyond ;  g,  rectus ;  h,  descending  colon ;  i,  transverse 
colon  ;  3,  aorta  ;  A-,  inferior  vena  cava  ;  I,  ureter. 

usually  does  not  need  to  be  cut.  At  the  seat  of 
the  operation  the  descending  colon  occupies  the 
angle  between  the  psoas  and  quadratus  lumborum 
muscles,  and  the  non-peritoneal  surface  is  exactly 


XVII]  COLOTOMY  411 

represented  by  that  part  of  the  bowel  that  faces 
this  angle  (Fig.  84).  Thus,  if  during  the  opera- 
tion the  curved  finger  be  placed  in  this  angle,  and 
the  patient  be  rolled  over  to  the  left  side,  the 
bowel  that  falls  into  the  finger  cannot  well  be 
other  than  the  descending  colon.  The  width  of  the 
non-peritoneal  surface  varies  from  fths  of  an  inch 
to  1  inch  in  the  empty  state,  and  may  attain  to 
2  inches  or  more  in  the  distended  condition 
(Braune). 

Iliac  or  inguinal  colotomy.  — -  In  this  very 
common,  excellent,  and  simple  operation  the  sig- 
moid flexure  is  exposed  and  opened  in  the  left 
iliac  region.  A  line  is  drawn  from  the  anterior 
superior  iliac  spine  to  the  umbilicus,  and  an  in- 
cision some  2  inches  in  length  is  made  at  right 
angles  to  this  line  and  at  a  distance  of  about 
lj  inches  from  the  point  of  the  bone.  The  three 
muscles  of  the  abdomen  and  the  peritoneum  hav- 
ing been  divided,  the  loop  of  the  sigmoid  flexure 
is  brought  into  the  wound,  is  secured,  and  is  (at 
once  or  at  a  later  period)  opened.  The  ascending 
branch  of  the  deep  circumflex  iliac  artery  crosses 
the  line  of  the  incision.  The  iliac  colon  is  bound 
by  a  very  short  mesentery  to  the  iliac  fossa,  but, 
owing  to  the  mobility  of  the  peritoneum  in  this 
region,  the  bowel  is  easily  brought  into  the 
wound. 

The  csecum  may  be  opened  on  the  right  side, 
and  as  a  rule  the  most  convenient  incision  is  an 
oblique  one  placed  externally  to  the  deep  epigastric 
artery.  The  appendix  has  also  been  opened  and 
sutured  to  the  incision  in  the  groin  (appendi- 
costomy).  Through  the  opening  in  the  appendix 
the  caecum  and  colon  may  be  irrigated  and 
washed  out. 

Colectomy  consists  in  excising  a  -portion  of 
the  colon.  The  csecum  has  been  removed,  and  con- 
siderable segments  of  the  rest  of  the  large  in- 
testine. ^  The  treatment  of  ^  cancer  of  the  colon 
by  excision  is  attended  with  considerable  suc- 
cess.    Portions  of  the  ascending  and  descending 


412         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

parts  of  the  colon  have  been  excised  through  an 
incision  in  the  loin,  but  colectomy  is  much  more 
readily  carried  out  through  an  anterior  wound. 
I  have  reported  a  case  in  a  young  girl,  in  which 
I  excised  the  whole  rectum  and  anus,  the  sig- 
moid flexure,  and  the  whole  of  the  descending 
colon.  The  divided  transverse  colon  was  broughi 
out  at  the  anus.  The  child  made  a  perfect  re- 
covery. The  parts  removed  are  in  the  Museum  of 
the  Royal  College  of  Surgeons.  The  operation 
of  intestinal  anastomosis  or  short-circuiting  is 
very  frequently  practised  on  the  colon.  Thus,  in 
an  obstruction  of  the  descending  colon  impossible 
of  removal,  the  transverse  colon  may  be  unitec 
to  the  sigmoid  flexure. 

In  more  recent  years  Mr.  Arbuthnot  Lane  has 
applied  excision  of  the  great  bowel  to  cases  of 
obstinate  constipation  which  are  unrelieved  by 
medical  measures,  especially  to  those  cases  where 
the  transverse  colon  is  greatly  elongated  and 
kinked  (see  p.  406).  In  cases  of  obstinate  colitis 
the  great  bowel  may  be  "  rested "  by  uniting  the 
lower  part  of  the  ileum  to  the  pelvic  colon,  thus 
short-circuiting  the  food  passage.  The  results  of 
such  operations  are  often  favourable,  and  have 
been  cited  in  support  of  the  theory,  promulgated 
by  Metchnikoff,  that  the  great  bowel  is  a  useless 
and  dangerous  structure  in  man.  The  evidence, 
so  far  as  it  goes,  indicates  that  no  colon  is 
better  than  a  diseased  colon,  but  it  certainly 
does  not  signify  that  no  colon  is  better  than 
healthy  one. 

Congenital  malformations  of  the  colon.— 
These  are  of  moment  with  regard  to  m  operative 
procedures.  It  may  be  very  briefly  said  that  in 
the  foetus  the  small  bowel  occupies  at  one  time 
the  right  side  of  the  abdomen,  while  the  large  gut 
is  represented  by  a  straight  tube  that  passes  on 
the  left  side  vertically  from  the  region  of  the 
umbilicus  to  the  pelvis.  ^  The  caecum  is  at  first 
situated  within  the  umbilicus,  and  then  ascends  in 
the  abdomen  towards  the  left  hypochondrium.     It 


XVII]  MALFORMATIONS    OF    COLON  413 

next  passes  transversely  to  the  right  hypochon- 
drium,  and  then  descends  into  the  corresponding 
iliac  fossa.  It  may  be  permanently  arrested  at 
any  part  of  its  course.  #  Thus  the  caecum  may  be 
found  about  the  umbilicus,  or  in  a  congenital 
umbilical  hernia,  or  in  the  left  hypochondriac 
region  (the  ascending  and  transverse  parts  -of  the 
colon  being  absent),  or  it  may  be  found  in  the 
right  hypochondrium,  the  ascending  colon  only 
being  unrepresented. 

The  whole  of  the  large  intestine  has  at  one 
time  an  extensive  mesentery,  and  in  some  rare 
cases  this  condition  may  persist  throughout  life. 
When  it  does  persist,  it  may  lead  to  one  form  of 
volvulus  of  the  bowel. 


CHAPTER   XVIII 

THE   ABDOMINAL   VISCERA   (concluded) 

The  liver.  —  The  liver  is  moulded  to  the  arch 
of  the  diaphragm,  and  lies  over  a  part  of  the 
stomach  (Fig.  85).  Properly  speaking,  it  has  only 
two  surfaces — a  visceral  surface,  which  in  the 
upright  posture  rests  on  the  stomach,  duodenum, 
gastro-hepatic  omentum,  neck  of  the  pancreas, 
hepatic  flexure  of  colon,  right  kidney,  and  right 
suprarenal  body;  and  a  parietal  surface,  in  con- 
tact with  the  diaphragm  and  anterior  belly  wall 
in  the  subcostal  angle.  As  seen  from  the  front  it 
is  triangular  in  outline,  with  its  apex  near  the 
apexofthe  heart  (Fig.  85);  its  upper  border  is 
best  indicated  by  a  line  commencing  at  the  apex 
beat  (Fig.  85)  and  passing  across  the  mid  line 
1  an  inch^  below  the  sterno-ensiform  point;  it 
ascends  as  it  reaches  the  nipple  line  to  the  level  of 
the  sterno-ensiform  plane.  The  lower  border  com- 
mences at  the  apex  beat,  crosses  the  mid  line  about 
1  inch  above  the  mid-epigastric  point,  reaches 
the  costal  margin  at^  the  outer  border  of  the 
rectus,  and  the  remainder  of  its  lower  border 
corresponds  to  the  costal  margin  as  far  as  the  tip 
of  the  eleventh  rib.  The  liver  is  in  contact  with 
the  right  kidney  along  the  lower  margin  of  that 
rib  (Fig.  89).  For  surgical  purposes  the  liver  in 
the  right  hypochondrium  may  be  regarded  as 
made  up  of  three  zones — an  upper  or  pulmonary, 
a  middle  or  pleural,  and  a  lower  or  diaphrag- 
matic (Fig.  85).  In  the  lower  zone,  which  is  l\  to 
414 


Chap.  XVIII] 


THE    LIVER 


415 


2  inches  wide  in  the  mid-axillary  line,  the  liver 
may  be  incised  or  explored;  in  the  middle  zone, 
which  is  of  equal  width,  the  pleural  reflection  is 
encountered.  In  the  erect  posture  the  lower  edge 
on  the  right  side  is  about  J  or  J  of  an  inch  below 
the  margins  of  the  costal  cartilages.  In  the  re- 
cumbent position  the  liver  ascends  about  an  inch, 


'J  STEBflO-EflSIF.  LlrtE 

Apex  Poi/it 

^PuLNONABy   LIWE 

_i Pleural  Li/ie 

TIepatic  Duct 

Cystic  Duct 
£  pancreas 

-duode/ium 

/I id  Epigastric  Li/ie 
IPylop-US 

+5T0WACM 

.Comaio/i5ileDuct 

±DuODEflU/1 

.^  Liaiea  Alba 

J  U/iBILICAL  U/1E 
Lt/1EA5EA»ILUA1ARI3 


Fig.  85.— Diagram  showing  the  position  of  the  liver,  gall- 
bladder, bile-ducts,  and  pancreas. 

The  lower  limits  of  the  pleura  and  lung  are  indicated. 

and  is  entirely  covered  by  the  costse,  except  at  the 
subcostal  angle.  It  descends  also  in  inspiration 
and  rises  in  expiration. 

The  fundus  of  the  gall-bladder  approaches  the 
surface  behind  the  ninth  costal  cartilage,  close  to 
the  outer  border  of  the  right  rectus  muscle  (Fig. 
85).  Its  position  is  extremely  variable ;  it  fre- 
quently occupies  a  position  considerably  below 
and  external  to  the  one  mentioned. 


416         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

The  liver  is  retained  in  shape  by,  and  moulded 
upon,  the  diaphragm  above  and  the  abdominal 
organs  below.  When  removed  from  the  body  the 
shape  is  lost  which  it  possesses  clinically.  It  pre- 
sents many  variations  in  form.  One  of  the  com- 
monest is  a  linguiform  process,  usually  known 
as  Riedel's  lobe,  which  projects  from  the  margin 
of  the  right  lobe  under  the  tenth  costal  cartilage 
(Fig.  76,  p.  378).  It  is  found  more  frequently  in 
women  than  in  men,  and  may  be  mistaken  for  a 
floating  kidney  or  an  abdominal  tumour. 

In  the  condition  known  as  ptosis  of  the  'liver 
the  organ  slides  from  the  dome  of  the  diaphragm, 
and  may  descend  to  the  level  of  the  umbilicus  or 
reach  the  iliac  fossa  (Fig.  76).  With  the  descent 
there  is  also  a  rotation  on  its  transverse  axis,  so 
that  its  dianhrasrmatic  surface  comes  almost  com- 
pletely to  the  front.  In  such  a  case  the  factors 
which  maintain  the  liver  in  position  have  to  be 
considered.  They  are  :  (1)  its  fixation  to  the 
diaphragm  by  the  inferior  ^  vena  cava  and  the 
fibrous  tissue  on  the  non-peritoneal  posterior  sur- 
face of  the  right  lobe  in  the  neighbourhood  of 
the  inferior  vena  cava.  (2)  The  peritoneal  folds, 
which  include  the  right  and  left  lateral,  coronary, 
and  falciform  ligaments,  also  attach  it  to  the 
diaphragm.  These  folds  are  lax,  in  order  to  allow 
the  free  movements  of  the  liver  which  occur  during 
respiration  and  in  the  filling  and  emptying  of 
the  stomach.  (3)  The  muscular  abdominal  walls. 
These  keep  the  other  abdominal  viscera  constantly 
pressed  against  the  lower  surface  of  the  liver. 
The  muscles  constitute  the  chief  means  for  main- 
taining the  liver  in  position.  ^  In  many  women 
over  40  the  right  lobe  of  the  liver  projects  quite 
2  inches  below  the  11th  rib,  and,  as  in  the  child* 
the  extremitv  of  the  left  lobe  frequently  comes 
in  contact  with,  or  even  overlaps,  the  upper  part 
of  the  snleen. 

The  liver  is  more  often  ruptured  from  con- 
tusion than  is  anv  other  abdominal  viscus.  This 
is  explained  by  Tts  large  size,   its  comparatively 


XVIII]  INJURIES    TO    THE    LIVER  417 

fixed  position,  its  great  friability  of  structure, 
and  the  large  quantity  of  blood  contained  in  its 
vessels.  A  normal  liver  will  take  its  own  weight 
of  blood  if  its  veins  be  injected  at  ventricular 
pressure  (Salaman).  Death  in  such  injuries 
usually  ensues  from  haemorrhage,  since  the  walls 
of  the  portal  and  hepatic  veins,  being  incorpo- 
rated with  the  liver  substance,  are  unable  to  re- 
tract or  to  collapse.  The  hepatic  veins  also  open 
direct  into  the  vena  cava,  and,  being  unprovided 
with  valves,  could  allow  of  the  escape  of  an 
immense  quantity  of  blood,  if  any  retrograde 
current  were  established.  The  hepatic  vessels 
are  thin-walled,  and  it  is  almost  impossible  to 
ligature  them,  except  by  buried  sutures.  It  is 
possible  for  the  liver  to  be  ruptured  without  the 
peritoneal  coat  being  damaged;  and  such  injuries 
may  be  readily  recovered  from.  The  liver  pre- 
sents, behind,  a  fairly  extensive  non-peritoneal 
surface,  at  which  rupture  or  wound  may  occur 
without  extravasation  into  the  abdominal  cavity. 
From  the  relation  of  the  liver  to  the  right  lower 
ribs,  it  follows  that  this  viscus  may  be  damaged 
when  the  ribs  are  fractured,  and  in  some  cases 
the  broken  ends  of  the  bones  have  been  driven 
through  the  diaphragm  into  the  liver  substance. 
Stabs  through  the  sixth  or  seventh  right  inter- 
costal space,  over  the  liver  region,  would  wound 
both  the  lung  and  the  liver,  would  involve  the 
diaphragm,  and  open  up  both  the  pleural  and 
peritoneal  cavities. 

The  intimate  relation  of  the  liver  to  the 
transverse  colon  is  illustrated  by  a  case  where 
a  toothpick,  4  inches  in  #  length,  was  found  in 
the  substance  of  the  liver.  It  had  worked 
its  way  there,  from  the  colon,  alon§  an  abscess 
cavity  that  connected  the  two  viscera.  _  The 
relation  of  the  liver  to  the  heart  may  be  illus- 
trated by  a  case  still  more  remarkable.  In  this 
instance  a  loose  piece  of  liver,  weighing  1 
drachm,  was  found  in  the  pulmonary  artery.  The 
patient  had  been  crushed  between  two  wagons, 
o 


418         THE    ABDOxMEN    AND    THE    PELVIS    [Chap. 

the  liver  was  ruptured,  and  the  diaphragm  torn. 
A  piece  of  the  liver  had  been  squeezed  along  the 
vena  cava  into  the  right  auricle,  whence  it  had 
passed  into  the  right  ventricle,  and  so  into  the 
pulmonary  artery.  The  heart  itself  was  quite 
uninjured.  Portions  of  the  liver  may  protrude 
through  abdominal  wounds,  and  are  usually  easy 
to  reduce.  In  one  instance  of  such  protrusion  the 
surgeon  did  not  find  the  reduction  easy,  so  he 
placed  a  ligature  round  the  projecting  part  of 
the  viscus,  and  then  cut  this  obstinate  portion 
of  the  liver  off.  The  patient  recovered.  Con- 
siderable portions  of  the  liver  have  been  removed 
with  success.  It  is  remarkable  from  what  grave 
injuries  of  the  liver  recovery  is  possible.  Thus,  Dr. 
Gann  {Lancet,  June,  1894)  reports  the  case  of  a 
man  of  28,  who  had  a  harpoon  driven  through  the 
whole  thickness  of  the  right  lobe  of  the  liver,  so 
that  it  projected  at  the  posterior  border.  The 
blade  was  7  inches  long,  and  had  two  barbs.  It 
was  removed  by  operation  twenty-eight  hours 
after  the  accident,  and  the  patient  made  a  good 
recovery. 

From  a  reference  to  the  relations  of  the  liver  it 
will  be  readily  understood  that  an  hepatic  abscess 
may  open  into  the  pleura,  and  in  some  cases, 
indeed,  the  pus  from  the  liver  has  been  discharged 
from  the  bronchi.  Thus,  it  has  been  possible  for  a 
patient  to  cough  up  some  portion  of  his  liver, 
although,  of  course,  in  a  very  disintegrated  and 
minute  form.  Hepatic  abscess  may  burst  in  one 
or  other  of  the  following  directions,  placed  in 
order  of  their  frequency  :  (1)  into  the  right  lung; 
(2)  into  the  bowel;  (3)  upon  the  surface  of  the 
body.  Such  abscesses  have,  in  rare  cases,  opened 
into  the  stomach.  The  liver  is  very  frequently 
the  seat  of  the  secondary  abscess  of  pyaemia,  and, 
according  to  Mr.  Bryant's  statistics,  abscesses  in 
this  viscus  are  more  common  after  injuries  to  the 
head  than  after  injuries  elsewhere.  They  are 
rare  in  pyaemia  following  affections  of  the  urinary 
organs,  and  are  equally  rare  in  the  pyaemia  after 


XVIII]  THE    GALL-BLADDER  419 

burns.  Secondary  deposits  of  tumours  and  ab- 
scesses are  frequently  limited  to  the  right  or  to 
the  left  of  a  line  drawn  from  the  fundus  of  the 
gall-bladder  to  the  inferior  vena  cava.  This  re- 
markable limitation  is  to  be  explained  by  the  fact 
that  the  liver  to  the  .right  of  this  line  is  supplied 
only  by  the  right  terminal  division  of  the  portal 
vein,  while  the  part  to  the  left  receives  blood  only 
from  the  left  division  (Cantlie). 

The  gall-bladder  may  be  absent,  as  is  the 
case  with  some  animals,  or  reduced  to  a  cicatrix 
from  disease.  It  is  often  removed  by  operation, 
and  no  disturbance  in  the  biliary  function  is 
apparent  (Moynihan).  Its  mucous  membrane  has 
a  peculiar  reticulated,  honeycomb  appearance,  and 
is  made  up  of  columnar  epithelium,  which  secretes 
mucus  and  has  a  power  of  absorption.  When 
inflamed  the  cells  pour  out  a  morbid  amount  of 
secretion,  in  which  the  cholesterin  of  the  bile  may 
become  deposited  if  the  outflow  is  obstructed, 
and  may  form  the  nuclei  of  gall-stones.  These 
are  composed  mostly  of  cholesterin,  a  normal  con- 
stituent of  bile,  and  vary  in  size  from  a  hemp 
seed  to  a  hen's  egg.  The  escape  of  gall-stones 
is  rendered  more  difficult  by  the  presence  of  a 
spiral  fold  of  mucous  membrane  in  the  neck  and 
duct  of  the  gall-bladder.  The  gall-bladder,  at  its 
neck,  forms  an  acute  angle  with  the  cystic  duct, 
the  spiral  fold  being  necessary  to  keep  the  passage 
open.  In  the  erect  position  the  long  axis  of  the 
gall-bladder  is  directed  upwards  and  backwards, 
and  the  cystic  duct  downwards  and  forwards 
(Fig.  ^  85).  The  cystic  duct  lies  in  the  gastro- 
hepatic  omentum,  where  it  joins  the  hepatic  to 
form  the  common  bile-duct.  It  is  accompanied  by 
the  cystic^  artery.  The  cystic  veins  pass  directly 
into  the  liver  and  end  in  the  portal  capillary  sys- 
tem^ m  In  cases  of  cystitis  the  part  of  the  liver 
receiving  the  cystic  veins  is  seen  to  be  contracted 
or  atrophied. 

A  gall-stone  may  be  arrested  in,  and  require 
removal  from,  any  part  of  the  cystic  or  common 


420         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

bile-ducts.  The  common  bile-duct  is  3  inches  long, 
and  its  lumen  £th  of  an  inch  wide,  but  by  the  pas- 
sage of  the  gall-stones  it  may  become  three  times 
its  normal  diameter.  The  upper  half  of  the  com- 
mon bile-duct  lies  in  the  gastro  hepatic  omentum, 
in  front  of  the  foramen  of  Winslow,  with  the 
portal  vein  behind  it  and  to  the  right.  The 
hepatic  artery  lies  close  to  it  on  the  left,  and  its 
branch,  the  superior  pancreatico-duodenal,  crosses 
the  common  bile-duct  as  it  passes  to  its  second 
or  deeper  stage.  A  stone  arrested  in  the  lower 
half  of  the  duct  is  difficult  of  access.  The  duct 
lies  buried  between  the  head  of  the  pancreas  be- 
hind and  the  duodenum  in  front  and  to  the  outer 
side.  It  may  be  necessary  in  such  a  case  to  open 
the  duodenum  and  extract  the  stone  through  its 
posterior  and  inner  wall,  or  the  duodenum  and 
head  of  the  pancreas  may  be  turned  forwards  from 
the  inner  border  of  the  right  kidney,  thus  expos- 
ing the  lower  half  (post-duodenal  stage)  of  the 
common  bile-duct  in  the  groove  between  the  duo- 
denum and  pancreas.  The  terminal  half-inch  is 
embedded  in  the  wall  of  the  duodenum  and  ends 
in  the  ampulla  of  Vater.  At  its  termination, 
where  the  duct  is  narrowest,  it  is  surrounded  by 
a  sphincter  which  regulates  the  flow  of  bile.  The 
lumen  of  the  lower  half  of  the  duct  is  less  than 
that  of  the  upper  half.  Two  lymphatic  glands 
lie  in  the  gastro-hepatic  omentum  by  the  side  of 
the  bile-duct,  and  have  been  mistaken  for  gall- 
stones when  calcified. 

The  gall-bladder  receives  its  nerve  supply  from 
the  eighth  and  ninth  segments  of  the  cord  (Head) 
through  the  great  splanchnic  and  coeliac  plexus. 
The  intense  colic  caused  by  gall-stones,  believed 
to  be  due  to  spasm  of  the  non-striated  muscular 
coat  of  the  bile-ducts,  is  reflected  along^  the  ninth 
dorsal  nerve  to  the  anterior  abdominal  wall. 
Stimulation  of  the  sympathetic  nerves  causes  the 
muscle  of  the  cystic  duct  to  contract,  but  relaxes 
that  of  the  gall-bladder  (T.  R.  Elliot).  The  con- 
tractions of  the  musculature  of  the  biliary  system 


xvim 


THE    GALL-BLADDER 


421 


are  correlated  with  the  movements  of  the  stomach, 
and  hence  are  liable  to  occur  soon  after  taking 
food  (Lynn  Thomas). 

The  gall-bladder  and  the  bile-duct  have  been 
ruptured  alone  without  rupture  of  the  liver.  The 
injury  is  rapidly  fatal,  owing  to  the  escape  of  bile 


Inferior  Vena  Cava 
Ster/io-E/isiform  Line 
Fundus  orbionAcn 
Liver 
Oesopnaqeal  Orifice 

SPLEEN 

Pulmonary  Line 
qnt  Suprarenal 

/Iid-epicastric  Line 
Pleural  line 
Pelvis  of  Kidney 

qnt  Kidney 

ector.  spinae 

scendimc  Colon 

uadr.atu5  luhborum 
Umbilical  Line 

RETER 


POST.  Sup  Iliac  Spine 


Fig.  86. — The  position  and  relationships  of  the  abdominal 
viscera  from  behind. 

The  lower  limits  of  the  pleura  and  lung  are  shown  in  red. 


into  the  peritoneal  cavity.  Large  gall-stones  may 
be  passed  direct  into  the  bowel  through  a  fistulous 
track  that  has  been  established  between  the  gall- 
bladder and  the  intestine.  Gall-stones  have  sup- 
purated out  through  the  anterior  belly-wall,  and 
have  been  removed  from  abscesses  in  the  parietes. 
Thus  Dr.  Burney  Yeo  reports  a  case  where  more 


422         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

than  one  hundred  gall-stones  were  discharged 
through  a  spontaneous  fistula  in  the  hypogastric 
region,  5  inches  below  the  umbilicus.  In  cases 
where  the  bile-duct  is  occluded  by  gall-stones,  or 
by  other  causes,  the  gall-bladder  may  become 
enormously  distended,  and  may  form  a  tumour 
extending  some  way  beyond  the  umbilicus.  So 
large  a  tumour  has  been  formed  that  the  mass  has 


Fig.  87. — Horizontal  section  through  upper  part  of 
abdomen.      (Riidinger.) 

a,  Liver  ;  b,  stomach  ;  c,  transverse  colon  ;  d,  spleen  ;  e,  kidneys  ; 
/,  pancreas,  f/,  inferior  vena  cava;  h  aorta  with  thoracic  duct 
hehind  it. 


been  mistaken  for  an  ovarian  cyst.  The  gall- 
bladder as  it  enlarges  tends  to  follow  a  line 
extending  from  the  ^  tip  of  the  right  tenth  car- 
tilage across  the  median  line  of  the  abdomen  below 
the  umbilicus.  For  the  relief  of  this  condition, 
cholecystotomy,  or  incision  into  the  gall-bladder, 
has  been  performed.  In  this  operation  the  in- 
cision or  puncture  is  made  over  the  most  promi- 
nent part  of  the  tumour.     Impacted  gall-stones 


XVIII]  THE    SPLEEN  423 

have  been  removed  entire  from  the  bile-duct 
through  an  incision  so  made,  or  the  stone  has  been 
crushed  in  situ  and  extracted  in  fragments. 

In  cholecystectomy  the  whole  of  the  gall-blad 
der  is  excised  and  the  cystic  duct  closed.  The  bile 
finds  its  way  into  the  intestine  direct  through  the 
common  duct. 

In  cholecystenterostomy  a  fistula  is  established 
between  the  gall-bladder  and  the  intestine.  The 
operation  is  carried  out  in  cases  in  which  there 
is  an  insuperable  obstruction  in  the  common  duct. 
The  gall-badder  thus  takes  the  place  of  the  com- 
mon duct. 

The  spleen. — The  spleen  is  deeply  situated  in 
the  left  hypochondriac  region,  and  in  the  normal 
condition  cannot  be  palpated,  being  quite  covered 
in  front  by  the  cardiac  end  of  the  stomach  (Fig. 
87).  It  most  closely  approaches  the  surface^  in 
the  parts  covered  bv  the  tenth  and  eleventh  ribs. 
Above  this  it  is  entirely  overlapped  by  the  edge 
of  the  lung.  It  is  in  all  parts  separated  from 
the  parietes  by  the  diaphragm.  "  It  lies  very 
obliquely,  its  long  axis  coinciding  almost  exactly 
with  the  line  of  the  tenth  rib.  Its  highest  and 
lowest  points  are  on  a  level,  respectively,  with  the 
ninth  dorsal  and  first  lumbar  spines;  its  inner 
end  is  distant  about  \\  inches  from  the  median 
plane  of  the  body,  and  its  outer  end  about  reaches 
the  mid-axillary  line"  (Quai-n)  (Fig.  86).  It  pos- 
sesses three  surfaces,  gastric,  renal,  and  phrenic, 
well  shown  in   Fig.   87 . 

A  dislocated  or  floating  condition  of  the  spleen 
is  rare.  Its  renal  surface  is  fixed  firmly  to  the 
upper  half  of  the^  left  kidney ;  its  gastric  surface 
is  kept  in  apposition  to  the  stomach  by  the  gastro- 
splenic  omentum ;  its  upper  pole  is  attached  near 
the  cardiac  orifice  of  the  stomach  by  a  suspen- 
sory fold  of  peritoneum,  while  its  lower  rests  on 
the  costo-colic  peritoneal  fold,  and  has  the  tail  of 
the  pancreas  and  colon  in  contact  with  it.  The 
tension  of  the ^  abdominal  walls  exerts  a  general 
pressure    on    it    through    the    other    abdominal 


424         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

organs.  When  the  spleen  enlarges,  as  in  ague,  ite 
crenated  anterior  border  may  be  felt  beneath  the 
tenth  costal  cartilage.  The  movable  or  floating 
spleen  is  met  with  only  in  adults.  The  organ  may 
be  so  displaced  as  to  reach  the  iliac  fossa. 

Injuries.— Although  extremely  friable  in  struc- 
ture, the  normal  spleen  is  not  very  frequently 
ruptured.  Its  connexions,  indeed,  tend  to  mini- 
mise the  effects  of  concussions  and  contusions. 
When  the  spleen,  however,  is  enlarged,  it  is  very 
readily  ruptured,  and  often  by  quite  insignifi- 
cant violence.  Thus,  several  cases  have  been  re- 
corded of  rupture  ofan  enlarged  spleen  by  mus- 
cular violence.  For  instance,  a  woman  ruptured 
her  spleen  in  an  attempt  to  save  herself  from  fall- 
ing, and  another  in^  springing  aside  to  avoid  a 
blow.  The  patients  in  each  instance  were  natives 
of  India,  and  the  latter  case  gave  rise  to  a  charge 
of  homicide.  The  spleen  being  extremely  vas- 
cular, it  follows  that  ruptures  of  the  viscus  are 
usually,  but  not  necessarily,  fatal  from  haemor- 
rhage. It  is  well  to  note,  in  connexion  with  this 
matter,  that  the  spleen  contains  most  blood  during 
digestion.  A  case  is  reported,  however,  of  a  boy 
who  met  with  an  accident  just  after  dinner,  and 
who  managed  to  walk  some  distance,  although  his 
spleen,  as  the  autopsy  revealed,  was  separated  into 
three  portions.  He  lived  some  days.  In  severe 
fractures  of  the  ninth,  tenth,  and  eleventh  ribs 
the  spleen  may  be  damaged  and  lacerated. 

The  capsule  of  the  spleen  contains  muscular 
tissue,  and  must  possess  some  contractile  power. 
This  f  act#  may  serve  to  explain  cases  of  recoverv 
from  limited  wounds  of  the  organ,  such  as  small 
gunshot  wounds.  In  such  lesions  the  capsule  may 
contract  and  greatly  narrow  the  hole  in  the  viscus, 
while  the  track  of  the  bullet  or  knife  may  become 
filled  with  blood-clot,  and  the  bleeding  thus  be 
staved. 

The  spleen  may  be  greatlv  enlarged  in  certain 
diseased  conditions.  The  hypertrophied  spleen 
may  attain  such  dimensions  as  to  fill  nearly  the 


XVI11J  THE    PANCREAS  425 

whole  abdomen,  and  in  one  case  a  cystic  tumour  so 
completely  occupied  both  iliac  fossae  that  it  was 
mistaken  for  an  ovarian  cyst,  and  the  operation 
for   ovariotomy    was   commenced. 

Extirpation  of  the  spleen  has  been  successful 
in  cases  of  abdominal  wounds  with  protru- 
sion of  the  viscus.  It  has  also  been  performed 
with  fair  results  in  many  cases  of  hypertrophied 
spleen,  and  of  wandering  spleen.  The  operation 
is  not  justifiable  in  cases  of  leuksemic  enlargement 
of  the  organ,  it  having  proved  invariably  fatal 
in  such  instances.  In  cases  of  wounds  with  pro- 
trusion, the  spleen  is,  of  course,  removed  through 
the  wound.  The  splenic  artery,  with  its  large 
accompanying  vein,  lies  in  the  lieno-renal  liga- 
ment, in  contact  with  the  tail  of  the  pancreas 
below. 

The  pancreas  lies  behind  the  stomach,  in 
front  of  the  first  and  second  lumbar  vertebrae 
(Fig.  85).  It  crosses  the  middle  line  behind  the 
mid-epigastric  line  (Fig.  85).  In  emaciated  sub- 
jects, and  when  the  stomach  and  colon  are  empty, 
it  may  sometimes  be  felt  on  deep  pressure,  espe- 
cially in  those  who  are  the  subjects  of  visceroptosis ; 
prolapse  of  the  stomach  leaves  the  pancreas  ex- 
posed above  the  lesser  curvature.  It  is  in  relation 
with  many  most  important  structures.  So  closely 
is  it  mixed  up  with  the  solar  plexus  that  this 
structure  is  necessarily  involved  in  inflammatory 
conditions,  and  must  be  disturbed  in  any  operative 
procedures  on  its  head  and  neck.  It  has,  I  be- 
lieve, never  been  ruptured  alone,  and  it  could 
scarcely  be  wounded  without  the  wound  implicat- 
ing other  and  more  important  viscera.  It  has 
been  found  herniated  in  some  very  rare  cases  of 
diaphragmatic  hernia,  but  never  alone.^  The  main 
duct  (duct  of  Wirsung)  usually  terminates  with 
the  common  bile-duct  in  the  ampulla  of  Vater 
(Fig.  88,  a),  so  that  a  gall-stone  arrested  at  this 
point  may  occlude  both  ducts  or  possibly  cause 
a  reflux  of  the  bile  within  the  pancreatic  duct. 
Not  uncommonly  (in  30  per  cent,  of  cases)  the 
o  * 


426 


THE    ABDOMEN    AND    THE    PELVIS    [Chap. 


ampulla  is  partly  (Fig.  88,  b)  or  completely 
divided  (Fig.  88,  c),  so  that  the  orifices  of  the  two 
ducts  are  separated ;  in  such  cases  occlusion  of 
the  termination  of  the  bile  passage  leaves  the  pan- 
creatic duct  free.  A  secondary  duct  (the  duct 
of  Santorini)  is  present  in  a  more  or  less  de- 
veloped condition  in  50  per  cent,  of  subjects.  It 
may  form  a  connexion  with  the  main  duct,  as 
in  Fig.  88,  A,  or  be  merely  a  minute  ductule,  as  in 


Fig.  88. — Diagrams  to  show  the  variations  in   the  manner 
of  termination  of  the  pancreatic  and  bile-ducts. 

A,  Form  in  which  the  common  bile-duct  (C,  B,  D)  and  main  pan- 

creatic duct  (B)  end  in  an  ampulla  (E).    A,  Duct  of  Santorini ; 
i.,  ii.,  iii.,  first,  second,  and  third  stages  of  the  duodenum. 

B,  Form  in  which  the  ampulla  is  partly  divided.    The  duct  of  San- 

torini is  shown  in  its  reduced  form. 

C,  Form  in  which  the  common  bile-duct  and  pancreatic  duct  have 

separate  openings  into  the  duodenum.    The  duct  of  Santorini  is 
absent. 


Fig.  88,  b.  .  The  accessory  duct  opens  nearer  the 
pylorus,  being  §  of  an  inch  above  the  ampulla 
of  Vater.  The  ampulla  usually  extends  into  a 
papilla  which  projects  within  the  duodenum,  but 
this  papillated  condition  is  not  always  present. 
Septic  conditions  may  spread  from  the  duodenum 
to  the  pancreas  or  gall-bladder  by  means  of  their 
ducts. 

The  common  bile-duct  in  its  second  stage  lies 
between  the  head  of  the   pancreas  and  the  duo- 


XVIII]  ISLETS    OF    LANGEKHANS  427 

denum.  It  thus  happens  that  in  carcinoma  of 
this  part  of  the  gland  the  duct  may  become  en- 
tirely occluded  and  jaundice  result.  Or  the  duo- 
denum and  even  the  colon  may  be  more  or  less 
obstructed  by  pressure,  or  the  neighbouring 
vessels  be  closed.  Cancer  of  the  pylorus  may 
spread  to  the  head  of  the  pancreas  by  direct 
extension.  The  lymphatics  of  the  two  parts  also 
freely  communicate. 

The  pancreas  lies  behind  the  lesser  sac  of  the 
peritoneum,  its  anterior  surface  being  covered  by 
the  posterior  wall  of  the  sac.  It  lies  in  front  of 
the  aorta,  in  the  fork  between  the  coeliac  axis 
above  and  the  superior  mesenteric  artery  below. 
The  portal  vein  passes  upwards  behind  the  neck 
of  the  gland. 

Islets  of  Langerhans. — When  microscopic  sec- 
tions of  the  pancreas  are  examined,  numerous 
small  groups  of  cells  are  observed  among  the 
normal  acini  of  the  gland.  These  islets  of  Lan- 
gerhans are  acini  of  the  gland  which  have  become 
modified  to  form  an  internal  secretion  (Swale 
Vincent).  They  vary  in  number  from  300to  400 
(M.  A.  Lane).  The  pathological  proof  ^  is  now 
definite  that  destruction  of  these  islets  gives  rise 
to  diabetes  (Mayo  Robson). 

The  kidney. — The  relations  of  this  organ  are 
as  follows  : — 

In  front. 

Right.  Left. 

Visceral  surface  of  liver.  Fundus  of  stomach. 

Second  part  of  duodenum.  Descending  colon. 

Commencement  of  transverse  colon.  Pancreas. 

Ascending  colon.  Spleen. 


Externally. 
Liver. 


Kidney. 


Externally. 
Spleen. 


Behind. 


Lower  part  of  arch  of  diaphragm. 

Quadratus  lumborum.    Psoas.    Transversalis. 

ast  rib  and  transverse  processes  of  upper  two  lumbar  vertebra-. 


428         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

The  kidneys  are  deeply  placed,  and  cannot  be 
felt  or  distinctly  identified  when  normal.  They 
are  most  accessible  to  pressure  at  the  outer  edge 
of  the  erector  spinae,  just  below  the  last  rib  (Figs. 
86  and  89).  The  dullness  of  the  right  kidney 
merges  above  in  that  of  the  liver,  while  on  the  left 
side  it  is  impossible  to  distinguish  between  the 
dullness  of  the  kidney  and  spleen.  The  right 
kidney  lies  usually  lower  down  than  does  the  left; 
but  even  the  lower  pole  of  the  right  kidney  is  an 
inch  above  the  crest  of  the  ilium,  or — what  for 
practical  purposes  is  the  same  level — above  the 
umbilical  line  (Fig.  75,  p.  376).  The  simplest 
manner  of  indicating  the  position  of  a  kidney  is 
to  mark  out  the  position  of  the  upper  and  lower 
pole  and  between  those  two  points  mark  on  the 
well-known  form  of  the  kidney.  The  lower  pole 
of  the  right  organ  lies  about  \  an  inch  outside 
the  prominent  lateral  border  of  the  erector  spinae 
and  1  inch  above  the  iliac  crest  (Fig.  86);  since 
the  kidney  is  about  4  inches  long  and  is  situated 
obliquely — its  long  axis  corresponding  to  that 
of  the  12th  rib — its  upper  pole  is  sufficiently  in- 
dicated by  taking  a  point*  4  inches  above  and 
1^  inches  internal  to  the  position  of  the  lower 
pole.  The  spine  of  the  11th  dorsal  vertebra — which 
may  be  identified  when  the  patient  bends  by  its 
anti-clinal  direction  and  semiiumbar  form — is 
just  below  the  level  of  the  upper  pole.  On  an 
average  the  left  kidney  lies  \  an  inch  higher  than 
the  right  (Addison).  In  many  instances  in  the 
female  its  lower  end  reaches  the  iliac  crest,  and 
may  even  go  below  it.  Such  positions  are  much 
less  common  in  the  male.  The  hilum  lies  about 
2  inches  from  the  middle  line,  and  is  opposite 
to  the  1st  lumbar  spine  and  usually  in  the  gap 
between  the  transverse  processes  of  the  1st  and 
2nd  lumbar  vertebrae  (Fig.  86).  In  radiograms 
of  the  injected  ureter  the  shadow  of  the  pelvis  of 
the  kidney  is  seen  to  fall  across  those  of  the 
transverse  processes  just  mentioned,  and  also  that 
of  the  last  rib   (Fig.   90). 


XVIII] 


THE    KIDNEY 


429 


The  anterior  surface  is  but  slightly  covered  by 
peritoneum,  being  only  in  contact  with  that  mem- 


Fig.  89. — Showing  the  relationshipsiof  thejkidney  and  colon 
in  the  lumbar  region  from  behind.  (Adopted  from 
3ferkel.y 

P.L.,  Lower  line  of  pleura  ;  XI.,  eleventh  rib  ;  XII.,  twelfth  rib ;  12th 
d.n., twelfth  dorsal  nerve;  1st  l.n.,  ilio-inguinal  and  ilio-hypo- 
gastric  nerves  :  A.B.,  vertical  line  representing  position  of  descend- 
ing colon  (desc.  c.)  ;  Q.L.,  quadratus  lumborum  ;  E.S.,  erector 
spinse  ;  peritoneum  (perit.)  is  shown  reflected  from  the  front  of 
the  kidney  to  the  colon  on  the  right  side. 


brane  in  such  parts  as  are  not  in  relation  with 
the  cellular  tissue  at  the  back  of  the  colon  and  at 

*  The  kidneys  are  represented  in  the  position  they  assume  when  the 
body  is  turned  on  its  face  ;  in  the  supine  position  they  fall  inwards  and 
backwards  into  the  position  described  in  the  text.  In  the  subject 
figured  above,  the  12th  rib  is  shorter  than  is  common. 


430         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

the  back  of  the  duodenum  or  pancreas.  The  ex- 
ternal border  is  more  closely  in  connexion  with 
the  peritoneum,  while  the  posterior  surface  is 
quite  devoid  of  that  membrane  (Figs.  86  and  87). 
Crossing  the  posterior  surface  of  the  kidney 
obliquely  from  above  downwards  and  outwards 
are  branches  of  the  last  dorsal  nerve  and  of  the 
first  lumbar  artery,  together  with  the  ilio-hypo- 
gastric  and  ilio-inguinal  nerves  (Fig.  89). 

Rupture  of  the  kidney  is  more  often  recovered 
from  than  is  a  like  lesion  of  any  other  of  the 
more  commonly  injured  abdominal  viscera.  This 
depends  upon  its  extensive  non-peritoneal  surface, 
whereby  the  extravasation  of  blood  and  urine  that 
follows  the  accident  is  very  often  entirely  extra- 
peritoneal. The  gland  may  be  readily  wounded 
from  behind  or  from  the  loin,  without  the  peri- 
toneum being  injured.  When  the  spine  is  much 
bent  forwards,  the  kidney  lies  in  the  angle  of  the 
bend,  at  a  part  where  the  flexion  of  the  column 
is  the  most  acute.  In  extreme  flexion,  therefore, 
of  the  spine,  it  may  be  squeezed  betweenthe  ilium 
and  the  lower  ribs.  Thus,  hematuria  is  not  un- 
common after  injuries  to  the  back  associated 
with  extreme  bending  of  the  spine  forwards, 
as  when  a  heavy  weight  falls  upon  the  bowed 
shoulders. 

The  kidney  is  embedded  in  a  large  quantity 
of  loose  fatty  tissue  constituting  the  perirenal 
capsule,  and  suppuration  extending  in  this  tissue 
constitutes  a  perinephritic  abscess.  Such  an  ab- 
scess may  be  due  to  disease  of  the  kidney 
itself,  to  affections  of  the  adjacent  parts  (spine, 
colon,  etc.),  or  to  injuries.  The  pus  is  at  first 
in  front  of  the  quadratus  lumborum,  and  then 
usually  makes  its  way  through  that  muscle  or 
through  the  lumbar  fascia.  It  then  presents  itself 
at  the  outer  edge  of  the  erector  spinse,  having 
passed  between  the  adjacent  borders  of  the  ex- 
ternal oblique  and  latissimus  dorsi  muscles.  It 
may,  however,  spread  into  the  iliac  fossa,  or  ex- 
tend into  the   pelvis   along  the   loose  connective 


XVIIIj  MOVABLE    KIDNEY  431 

tissue  behind  the  descending  colon  and  rectum, 
or  open  into  the  colon  or  bladder,  or  even  into  the 
lung.  Most  rarely  of  all  does  it  perforate  the 
peritoneum.  Renal  abscess  usually  opens  upon 
the  non-peritoneal  surface  of  the  gland.  It  may 
open  into  the  adjacent  colon.  In  one  case  a  renal 
abscess,  due  to  stone,  made  its  way  from  the  right 
kidney  into  the  pyloric  end  of  the  stomach,  so 
that  a  communication  was  established  between 
those  two  organs.  The  perirenal  fat  is  of  much 
surgical  importance,  as  its  laxity  permits  of  a 
ready  enucleation  of  the  organ.  It  is  more  abund- 
ant behind  than  in  front.  When  this  tissue  has 
been  destroyed  or  modified  by  inflammation,  the 
kidney  becomes  fixed,  and  its  removal  a  matter  of 
great  difficulty.  This  is  illustrated  by  the  re- 
moval of  a  large  tuberculous  kidney  which  has 
been  long  diseased.  Besides  the  perirenal  cap- 
sule, the  kidney  also  possesses  its  proper  capsule, 
which  can  be  easily  stripped  from  the  normal 
organ.  The  blood  pressure  in  the  renal  vessels 
renders  the  capsule  tense ;  in  inflammatory  con- 
ditions the  tension  may  become  so  great  as  to 
interfere  with  the  free  passage  of  blood  through 
the  kidney.  Incision  of  the  capsule  has  been 
proposed  to  relieve  such  congested  conditions. 

Movable  kidney.  —  The  kidneys,  being  closely 
applied  to  the  diaphragm,  necessarily  follow  its 
respiratory  movements;  in  normal  breathing  the 
up  and  down  excursion  of  the  kidney  is  about 
i  an  inch  in  extent.  The  perirenal  capsule  in 
which  the  kidney  is  loosely  embedded  is  merely  a 
specialized  part  of  the  subperitoneal  connective 
tissue.  The  parts  of  the  perirenal  capsule  have 
been  artificially  separated  into  prenephric  and 
postnephric  fascice  Joy  Zuckerkandl.  Above,  the 
perirenal  capsule  is  continuous  with  the  dense 
subperitoneal  tissue  on  the  diaphragm,  externally 
with  the  equallv  dense  layer  over  the  transversalis, 
internally  it  fuses  with  the  sheaths  of  the  in- 
ferior vena  cava  and  aorta,  while  below  it  is 
continued   downwards,    as  the   lax   subperitoneal 


432         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

tissue  surrounding  the  ureter,  to  become  con- 
tinuous with  the  corresponding  tissue  in  the 
pelvis.  Hence  only  downward  displacements  are 
possible.  The  perirenal  capsule  and  the  renal 
vessels,  while  they  restrict  and  determine  the 
direction  of  the  renal  movements,  only  come  into 
action  when  the  normal  limits  have  been  exceeded. 
The  force  which  retains  the  kidneys  in  position  is 
the  intra-abdominal  tension  maintained  by  the 
musculature  of  the  abdominal  wall,  by  which 
the  other  viscera  are  compressed  against  the  kid- 
neys. With  the  absorption  of  fat  from  the  cap- 
sule the  tissue  of  the  perirenal  capsule  becomes 
more  lax  and  the  renal  movements  more  free. 
Hence  movable  kidney  is  often  met  with  in  the 
badly  nourished.  It  is  far  more  common  in 
women  than  in  men.  In  the  former  sex  the  influ- 
ence of  pregnancy  appears  to  have  especial  effect, 
acting,  probably,  by  dragging  upon  the  peri- 
toneum, and  by  loosening  its  connexions,  as  well 
as  by  inducing,  after  delivery,  a  general  laxity 
of  the  abdominal  walls.  The  right  kidney  is  far 
more  often  movable  than  is  the  left,  owing  prob- 
ably to  the  displacing  influence  of  the  liver.  I 
have  recorded  (in  conjunction  with  Dr.  Mac- 
lagan)  three  cases  in  which  a  movable  kidney 
pressed  against  the  neck  of  the  gall-bladder  and 
obstructed  the  flow  of  bile.  The  movable  kidney 
can,  of  course,  only  be  displaced  within  a  seg- 
ment of  a  circle  whose  radius  corresponds  to  the 
length  of  the  renal  vessels,  and  yet  this  displace- 
ment may  be  considerable. 

The  dragging  pains  which  are  felt  with  a 
movable  kidney  are  due  to  a  stretching  of  the 
renal  plexus,  which  is  connected  with  the  solar 
plexus  and  enters  the  kidney  with  the  arteries. 
The  kidney  receives  its  nerve  supply  from  the 
10th,  11th,  12th  dorsal,  and  1st  lumbar  segments 
of  the  spinal  cord  through  the  small  and  lesser 
splanchnics  (Head).  Pain  is  referred  to  the  wall 
of  the  abdomen  along  the  sensory  nerves  derived 
from  these  segments. 


XVIII]  MISPLACED    KIDNEY  433 

Abnormalities  of  the  kidneys.— One,  or  loss 
frequently  both  kidneys  may  be  misplaced.  The 
left  is  more  often  out  of  place  than  the  right, 
and  may  be  found  over  the  sacro-ihac  synchon- 
drosis, or  the  promontory  of  the  sacrum,  or  be 
discovered  in  the  iliac  fossa  or  pelvis.  The  mis- 
placed kidney  is  often  misshapen.  The  kidney 
may    exhibit '  a   more    or   less   extreme    degree   of 


Upper   Pole  of  Kidney 


■Dilated  Pelvis 


Abnormal  Art. 


Fig.   89a. — An  abnormal   renal  artery  causing  kinking  at 
the     uretero-pelvic     junction,     and      hydronephrosis. 

{After  Hurry  Fen  wick.) 

lobulation,  a  condition  present  in  the  newly  born. 
The  ureter  may  be  double  in  its  upper  part  or 
throughout  its  whole  extent,  there  being  two 
ureteral  orifices  in  the  bladder.  Supernumerary 
arteries  are  frequently  present;  cases  have  been 
recorded  where  such  vessels,  passing  to  the  lower 
pole  of  the  kidney,  have  caused  constriction  or 
kinking  of  the  ureter,  and  hydronephrosis.  In 
a  series  of  cases  of  hydronephrosis,  Mr.  Hurry 
Fenwick    found   that   the   kinking  of   the    ureter 


434         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

was   due  to   an   abnormal  vessel   in   16  per  cent, 
of  cases  (Fig.  89a). 

The  kidneys  are  developed  in  the  pelvic  region, 
and  ascend  in  the  early  months  of  foetal  life  to 
a  lumbar  position.  New  renal  vessels  are  formed 
as  the  ascent  takes  place.  The  "sacral"  kidney 
is  one  which  has  been  arrested  in  its  ascent,  and 
the  blood  supply  is  drawn  from  the  common  iliac 
arteries.  Double  ureter  is  due  to  a  division  of 
the  primary  renal  bud. 

The  two  kidneys  may  be  fused.  "  The  lowest 
degree  of  fusion  is  seenin  the  horse-shoe  kidney. 
The  two  kidneys  are  united  at  their  inferior  por- 
tions by  a  flat,  riband-like,  or  rounded  bridge  of 
tissue,  which  crosses  the  vertebral  column.  In  the 
higher  degrees  the  two  lateral  portions  approach 
one  another  more  and  more  until  they  reach  the 
highest  degree,  in  which  a  single  disc-like  kidney, 
lying:  in  the  median  line,  and  provided  with  a 
double  or  single  calyx,  represents  complete 
fusion"  (Eokitansky).  When  the  two  kidneys  are 
united  by  a  web  of  connective  tissue,  the  condi- 
tion is  no  bar  to  operation.  There  may  be  an 
entire  absence  of  one  kidney.  The  single  kidney 
may  be  lateral  or  median  in  position.  Sir  Henry 
Morris  gives  the  following  estimate  of  the  fre- 
quency of  these  abnormal  conditions  :  Congenital 
absence  or  extreme  atrophy  of  one  kidney  may  be 
expected  in  about  one  in  4,000  cases,  the  horse- 
shoe kidney  in  one  in  1,600,  and  the  single  fused 
kidney  in  one  in  8,000  cases.*  . 

Operations  on  the  kidney, —  (1)  Nephrotomy. 
Incision  into  the  kidney  for  exploration,  or  the 
evacuation  of  pus.  (2)  N ephro-lithotomy.  In- 
cision into  the  gland  for  the  removal  of  a  calculus. 

(3)  Nephrectomy.     Removal  of  the  entire  organ. 

(4)  N  ephrorrhaphy.  ^  The  operation^  of  securing  a 
movable  kidney  in  its  normal  position.  In  the 
first,    second,    and   fourth   operations   the   kidney 

*  For  fuller  details  regarding  abnormalities  of  kidneys,  see  "  Urinary 
Surgery,"  by  F.  S.  Kidd. 


XVIII]  RELATIONS     OF    KIDNEY 


435 


Sup.  LohcSihus 


i/ihomihate  art. 
Trachea 

Oesophagus 
Vena  Azyqos  Major 
Right  Luhc 
Thoracic  Duct 
Diaphragm 

l£_R'CMT  KlD/iEY 

Ureter 
Spermatic  Vessels 

Ihf.  Veha  Cava 
Bifurcation  op  Aorta 
Cluteus/^edius 
Psoas 
Rectum 

Sup.  /Iaemorrh.Art. 
Gluteus  Maximus 


Fig.  90.— View  of  the  kidneys,  etc.,  from  behind.       {After 

Riidinger.) 


43G         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

is  reached  through  the  loin.  In  nephrectomy  the 
incision  is  carried  backwards  about  1  inch  over 
the  erector  spinse,  and  a  part  of  the  quadratus 
lumborum  will  be  divided  (see  Fig.  89).  The 
costo-vertebral  ligament,  a  specialized  part  of 
the  middle  layer  of  the  lumbar  fascia  which 
binds  the  last  rib  to  the  tips  of  the  upper 
two  lumbar  transverse  processes,  also  falls  in 
the  line  of  the  incision.  The  perirenal  capsule 
is  opened  up,  and  the  gland  enucleated  from 
the  capsule  of  fat  in  which  it  lies.  In 
some  instances  the  last  rib  has  been  resected  to 
obtain  more  space  for  the  operation.  The  pleura 
reaches  the  neck  of  the  12th  rib  and  occasionally 
it  descends  as  far  as  the  transverse  process  of 
the  1st  lumbar  vertebra  (Figs.  86  and  89).  In 
one  case  the  12th  rib  was  rudimentary,  and  the 
11th  rib  was  removed  under  the  impression  that 
it  was  the  12th.  The  pleura  was  opened  and 
death  ensued. 

When  the  kidney  is  free  from  its  fatty  capsule, 
the  vessels  at  the  hilum  are  secured  separately  by 
ligatures.  The  numerous  nerves  to  the  kidney 
are  no  doubt  included  with  the  vessels.  They  con- 
stitute a  surgical  pedicle  of  the  kidney.  At  the 
hilum  the  vein  lies  in  front,  the  artery  and  its 
branches  next,  and  the  ureter  behind  and  towards 
the  lower^  part.  The  artery  is  about  the  size  of 
the  brachial,  and  usually  divides  into  four,  five, 
or  six  branches  before  it  reaches  the  kidney. 
This  fact  must  be  borne  in  mind  if  the  structures 
at  the  hilum  are  separately  secured.  One-third 
of  these  branches  constantly  enter  the  hilum  be- 
hind the  ureter  and  are  liable  to  injury  in  ex- 
ploration of  the  pelvis  of  the  kidney.  The  vein 
is  also  represented  at  the  hilum  by  three  or  four 
branches.  Accessory  renal  arteries  maybe  present. 
Some  may  enter  the  upper  end  of  the  kidney  or  its 
anterior  surface.  In  removing  large  renal  tumours 
an  abdominal  incision  is  advised,  the  cut  being 
made  either  along  the  corresponding  semilunar 
line,  and  on  a  level  with  the  diseased  mass,  or  in 


XVIII]  SUPRARENAL    BODIES  437 

the  linea  alba.  The  abdominal  operation  is  the 
more  usual  one;  it  has  the  advantages  of  greater 
ease  and  rapidity  in  performance,  and  gives  an 
opportunity  of  examining  the  condition  of  both 
kidneys.  In  chronically  inflamed  conditions  of 
the  kidney — as,  for  example,  in  long-standing 
tuberculous  disease — the  kidney  becomes  adherent, 
and  on  the  right  side  is  apt  to  become  closely 
bound  down  to  the  vena  cava.  Much  care  is 
needed  in  clearing  the  great  vein  when  so  ad- 
herent. In  removing  a  very  adherent  kidney  the 
diaphragm  has  been  torn. 

The  suprarenal  bodies  are  situated  at  the 
upper  poles  of  the  kidneys,  but  are  more  closely 
united  to  the  diaphragm  than  to  these  organs, 
as  is  seen  from  the  fact  that  they  are  not  dis- 
placed with  the  kidneys.  The  right  body  lies 
behind  the  right  lobe  of  the  liver,  and  so  close  to 
the  inferior  vena  cava  that  the  two  may  become 
bound  by  inflammatory  adhesions.  They  are  glands 
which  form  an  internal  secretion  (adrenalin)  that 
is  evidently  concerned  in  regulating  the  tonus  of 
non-striated  muscle.  When  applied  directly,  it 
causes  constriction  of  arteries  and  a  narrowing 
of  the  bowel.  The  cortex  of  the  body  is  developed 
from  epithelium  covering  the  Wolffian  body,  and 
when  this  body  descends  with  the  genital  glands, 
detached  parts  may  accompany  these  organs  and 
form  suprarenal  tumours.  Parts  may  also  become 
embedded  in  the  kidneys  and  give  rise  to  peculiar 
renal  tumours.  The  medulla,  which  arises  with 
the  sympathetic  system,  receives  a  large  nerve 
supply  from  the  solar  plexus.  Disease  of  the 
suprarenals  may  cause  bronzing  of  the  skin ;  hence 
they  are  believed  to  be  concerned  in  the  formation 
of  body  pigment. 

The  ureters  are  strong  tubes  about  15  inches 
long;,  with  thick  muscular  walls,  and  are  placed 
entirely  behind  the  peritoneum.  The  average 
width  is  that  of  a  goose-quill.  The  ureter  rests 
from  above  downwards  upon  (1)  the  psoas  muscle 
and  the  genito-crural  nerve;  (2)  the  common  iliac 


438         THE    ABDOMEN    AND    THE    PELVIS    [Chap 

vessels  on  the  left  side,  and  the  external  iliac 
vessels  on  the  right;  (3)  after  passing  downwards 
on  the  internal  iliac  artery  it  then  enters  the 
posterior  false  ligament  of  the  bladder,  and  so 
reaches  the  bladder  wall.  In  the  female  it  passes 
through  the  base  of  the  broad  ligament,  where  the 
uterine  artery  loops  over  it  j  of  an  inch  from 
the  neck  of  the  uterus.  It  rests  on  the  roof  of 
the  upper  part  of  the  vagina  before  entering  the 
bladder,  and  a  calculus  arrested  in  that  stage  may 
be  distinctly  felt.  The  narrowest  part  of  the 
tube  is  the  portion  within  the  bladder  walls,  and 
when  renal  calculi  pass  along  the  ureter  they  are 
often  arrested  at  this  point.  There  are  two  other 
narrow  points  at  which  calculi  may  be  stopped  : 
at  its  junction  with  the  pelvis  of  the  kidney,  and 
where  it  crosses  the  pelvic  brim.  The  ureters  per- 
mit of  great  distension,  and  in  certain  cases  of 
gradual  dilatation  they  have  attained  a  width 
equal  to  that  of  the  thumb  and  even  of  the  small 
intestine.  Several  cases  are  recorded  of  rupture 
of  the  ureter  from  external  violence.  When  such 
an  accident  occurs  a  large  urinary  collection 
usually  forms  behind  the  peritoneum,  which,  lead- 
ing to  suppuration,  will  produce  a  fluctuating 
tumour  beneath  the  parietes. 

The  ureter  expands  in  the  hilum  of  the  kidney 
into  a  funnel-shaped  cavity — the  pelvis.  This  in 
turn  divides  into  the  calyces.  In  the  pelvis  or 
calyces,  calculi  are  frequently  lodged.  The  calyces 
are  too  narrow  to  admit  an  exploring  finger. 
The  ureter  has  been  successfully  resected  and 
sutured.  It  is  supplied  by  nerves  from  the  renal 
plexus  and  by  vessels  from  the  renal,  inferior 
vesical  and  subperitoneal  plexus.  Its  malforma- 
tions have  been  already  mentioned  (p.  433). 

In  the  search  for  impacted  calculi  by  the  aid 
of  X-rays  the  following  method  will  be  found 
useful  for  indicating  the  course  of  the  ureter. 
The  pelvis  of  the  kidney  lies  between  the  trans- 
verse processes  of  the  two  upper  lumbar  vertebrae 
(Fig.  91) ;  its  position  on  the  surface  of  the  body 


XVIII] 


URETERAL    CALCULI 


439 


may  be  indicated  by  taking  a  point  just  internal 
to  that  used  for  the  gall-bladder  (p.  415).  At 
the  brim  of  the  pelvis  the  ureter  crosses  at  or 
near  the  bifurcation  of  the  common  iliac  artery, 
a  point  which  lies  at  the  junction  of  the  upper 


iAodtic  Bifurcation 


Fig.  91. — Diagram  to  show  the  course  of  the  ureters  and 
position  of  the  bladder, 

As  they  appear  in  a  skiagram  when  they  have  been  injected  with  a 
bismuth  solution.  The  positions  of  the  fundus  of  the  uterus 
Fallopian  tubes,  and  ovaries  are  also  indicated. 


with  the^  lower  two-thirds  of  a  line  drawn  from 
the  aortic  bifurcation  to  the  femoral  point  (see 
Figs.  90  and  91,  and  72,  p.  352).  Its  pelvic 
course  is  curved  (Fig.  91),  the  convexity  of  its  out- 
ward bend  lying  \  an  inch  in  front  of  the  ischial 
spine.  The  vesical  orifice  is  to  be  sought  for  in 
a    skiagram    at    some    distance    above    and    inter- 


440         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

rial  to  the  pubic  spines.  Mr.  Rigby  has  shown 
that  the  ureter  may  be  exposed  from  behind 
through  the  sacro-sciatic  notch,  and  calculi  thus 
removed  from  it,  when  the  anterior  operation  is 
impracticable  on  account  of  pelvic  adhesions. 
He  uses  the  ischial  spine  as  a  guide  in  finding 
the  ureter. 

Nerve  supply  of  the  abdominal  viscera. 
— Some  account  has  been  given  of  the  nerves  which 
supply  the  abdominal  viscera  and  of  the  spinal 
segments  from  which  they  are  derived  (p.  349). 
These  viscera  are  mainly  supplied  by  the  sympa- 
thetic system  through  a  series  of  plexuses.  The 
most  important  of  these  is  the  solar,  from  which 
is  more  or  less  directly  derived  the  nerve  supply 
of  stomach,  liver,  spleen,  kidneys,  suprarenal  cap- 
sules, pancreas,  and  such  parts  of  the  intestine 
as  are  in  connexion  with  the  superior  mesenteric 
artery.  The  solar  plexus  and  its  appendages  re- 
ceive the  splanchnic  nerves  and  some  branches 
from  the  vagus,  while  communications  from  the 
phrenic  go  to  the  hepatic  and  suprarenal  plexuses. 
Through  these  nerves  the  calibre  of  the  blood- 
vessels and  the  amount  of  blood  in  the  abdomen 
are  regulated.  They  contain  not  only  sensory 
fibres  ior  the  abdominal  viscera  but  constrictor 
and  dilator  fibres  for  the  bowel.  It  may  be  well 
understood  that  an  impression  brought  to  bear 
upon  extensive  networks  with  such  wide  central 
connexions  and  with  such  important  relations 
would  produce  considerable  effects.  These  effects 
we  see  in  the  profound  collapse,  vomiting,  and 
other  grave  symptoms  that  attend  severe  injuries 
to  the  viscera,  and  especially  to  those  that  are  the 
most  directly  associated  with  these  large  plexuses. 
The  descending  colon  and  sigmoid  flexure  are 
supplied  by  the  inferior  mesenteric  plexus.  The 
upper  part  of  the  colon,  although  supplied  by 
the  superior  mesenteric  plexus,  is  only  supplied  by 
that  part  of  it  that  is  most  remote  from  the  great 
centres,  and  it  is^  a  conspicuous  fact  that  the 
nearer  the  lesion   is  to  the  stomach,   the  graver, 


XVIII 1  "SYMPATHETIC    PAINS"  441 

other  things  being  equal,  are  the  nervous  pheno- 
mena  produced. 

In  some  diseases  of  the  liver  and  stomach 
"  sympathetic"  pains  are  complained  of  between 
the  shoulders  or  about  the  inferior  angles  of  the 
scapulae.  They  commonly  appear  some  distance 
below  the  angle  of  the  scapula. .  The  nerves  for 
the  stomach  are  derived  principally  from  the 
seventh  and  eighth  and  those  for  the  liver  from 
the  eighth  and  ninth  spinal  segments.  The  skin 
areas  of  these  segments  may  become  tender^  when 
the  organs  are  diseased,  and  to  some  point  in 
these  areas  pain  is  referred  (Fig.  70,  p.  345).  The 
shoulder-tip  pain  that  often  accompanies  liver 
disease  is  situated  in  the  area  supplied  by  the 
fourth  cervical  segment,  the  same  segment  as  sup- 
plies sensory  fibres  to  the  diaphragm  and  sub- 
diaphragmatic connective  tissue  through  the 
phrenic  nerves.  It  will  be  remembered  that  these 
nerves  are  distributed  on  the  under  surface  of  the 
diaphragm. 

There  would  seem  to  be^  but^  little  connexion 
between  a  disease  in  the  sigmoid  flexure  and  a 
pain  in  the  knee,  yet  in  cases  of  cancer  in  this 
flexure,  and  in  instances  where  it  has  been  dis- 
tended with  faeces,  such  pain  has  been  complained 
of.  The  pain  is  conveyed  along  the^  obturator 
nerve,  which  lies  beneath  the  sigmoid  flexure, 
and  could  be  readily  pressed  upon  by  the  gut 
when  diseased.  Pain  arising  from  the  small  in- 
testine is  usually  referred  to  the  neighbourhood 
of  the  umbilicus — the  distribution  of  the  tenth 
dorsal  nerve  (Fig.  70,  p.  345).  It  seems  remark- 
able that  such  pains  should  be  restricted  to  so 
narrow  an  area,  but  a  full  explanation  of  this 
is  to  be  found  in  the  fact  that  the  whole  of  the 
small  intestine  arises  from  an  extremely  small 
part  of  the  embrvonic  alimentary  tract.  Pains 
along  the  groin  (along  the  12th  dorsal  and  1st 
lumbar  nerves)  arise  from  many  sources — from 
dis^ase^  of  the  kidnev,  ureter,  ovary,  testicles. 
Fallopian  tubes,  uterus,  appendix,  hip-joint,  and 


442         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

from  hernise.  Hence  a  pain  referred  to  this  region 
requires  that  all  these  parts  should  be  investigated 
as  to  the  source  of  the   disease. 

Blood-vessels  01  the  abdomen. — Some 
of  the  visceral  branches  of  the  abdominal  aorta 
are  of  large  size,  and  would  bleed  very  copiously 
if  wounded.  Thus,  the  cceliac  axis  and  the 
superior  mesenteric  artery  are  as  large  as  the 
common  carotid;  the  splenic,  hepatic,  and  renal 
vessels  are  about  the  size  of  ^  the  brachial ;  while 
the  largest  part  of  the  inferior  mesenteric  trunk 
has  dimensions  equal  to  those  of  the  ulnar  artery. 
Aneurysmsof  the  aorta  are  especially  apt  to  occur 
at  the  cceliac  axis,  that  being  a  point  where  a 
number  of  large  branches  are  abruptly  given  off, 
and  where  the  course  of  the  circulation  undergoes 
in  consequence  a  sudden  deviation.  Although 
two,  or  in  some  places  three,  anastomotic  arches 
occur  between  the  branches  of  the  superior  mesen- 
teric artery  before  they  form  a  final  network  in 
the  bowel,  yet  embolism  of  a  comparatively  small 
branch  may  lead  to  gangrene  of  the  gut  (Lock- 
wood). 

When  it  is  remembered  thatthe  lumbar  glands 
lie  about  the  vena  cava  and  iliac  veins,  it  will 
be  understood  that  great  enlargement  of  those 
bodies  may  cause  oedema  from  pressure.  Gan- 
grene of  the  whole  of  the  small  intestine  may 
result  from  an  embolism  of  the  portal  vein.  In 
a  case  reported  by  Mr.  Barnard  the  embolism  was 
caused  by  a  constriction  at  the  point  where  the 
vein  passes  behind  the  neck  of  the  pancreas.  The 
inferior  vena  cava  has  been  ligatured  success- 
fully :  amongst  the  collateral  veins  which  enlarge, 
the  chief  are  the  azygos,  epigastric,  and  intra- 
vertebral  veins. 

A  number  of  minute  but  most  important  anas- 
tomoses exist  between  some  of  the  visceral  branches 
of  the  abdominal  aorta  and  certain  of  the  vessels 
supplied  to  the  abdominal  parietes.  These  anasto- 
moses are  situated  behind  the  peritoneum  and 
mostly  concern  such  viscera  as  have  a  fair  sur- 


XVIII]  ABDOMINAL    BLOOD-VESSELS  443 

face  uncovered  by  that  membrane.  The  visceral 
branches  that  join  the  anastomoses  are  derived 
from  the  hepatic,  renal,  and  suprarenal  arteries, 
and  from  the  vessels  supplying  the  lower  part  of 
the  duodenum,  the  pancreas,  the  caecum,  and  the 
ascending  and  descending  segments  of  the  colon. 
The  parietal  vessels  joining  with  the  above  are 
derived  from  the  phrenic,  lumbar,  ilio-lumbar, 
lower  intercostal,  epigastric,  and  circumflex  iliac 
trunks.  In  a  case  detailed  by  Professor  Chiene 
(Journ.  Anat.  and  Phys.,  vol.  iii.)  the  cceliac 
axis  and  mesenteric  vessels  were  plugged,  but 
blood  in  sufficient  amount  to  supply  the  viscera 
had  reached  branches  of  these  arteries  through 
their  parietal  communications.  When  the  portal 
circulation  becomes  obstructed  owing  to  disease  of 
the  liver,  blood  from  the  portal  vein  may  pass 
into  the  systemic  veins  at  the  following  points  : 

(1)  lower  part  of  the  rectum,  from  the  superior 
to  the  inferior  and  middle  hsemorrhoidal  veins; 

(2)  at  the  oesophagus,  from  the  coronary  to  the 
oesophageal  veins ;  (3)  in  the  falciform  and  round 
ligaments,  from  the  portal  vein  to  tributaries  of 
the  epigastric;  (4)  in  the  subperitoneal  tissue  of 
the  posterior  wall  of  the  abdomen,  whereby  the 
renal,  phrenic,  lumbar,  and  intercostal  veins  re- 
ceive blood  from  mesenteric,  pancreatic,  and  other 
veins.  By  bringing  about  adhesions  between  the 
omentum  or  visceral  peritoneum  and  the  parietal 
peritoneum,  as  is  done  in  the  Talma-Morrison 
operation,  new  and  large  communications  are 
formed  between  the  portal  and  systemic  venous 
circulations.  Cases  have  been  recorded  of  com- 
munications between  the  external  iliac  vein  and 
the  portal  vein.  These  have  generally  been 
effected  by  the  deep  epigastric  vein  joining  with 
a  pervious  umbilical  vein  in  the  vicinity  of  the 
navel. 

Thoracic  duct. — The  thoracic  duct  may  be 
wounded  in  the  course  of  removing  tubercular 
glands  f rom^  beneath  the  lower  part  of  the  left 
sterno-mastoid ;  or,  as  in  some  reported  cases,  may 


444         THE    ABDOMEN    AND    THE    PELVIS 

be  severed  by  a  stab  in  the  neck.  In  each  case 
lymph  and  chyle  in  large  quantities  escaped 
from  the  wound.  The  duct  has  been  found  to 
have  been  obliterated,  and  that,  too,  without  pro- 
ducing any  marked  symptoms  during  life.  It  has 
been  cut  and  ligatured  during  removal  of  glands 
from  the  supraclavicular  triangle,  with  no  bad 
result.  Mr.  Leaf  has  shown  that  the  thoracic 
duct  communicates  freely  with  the  azygos  veins 
in  the  posterior  mediastinum  and  with  the  lym- 
phatic vessels  of  the  righfc  side  of  the  thorax  and 
neck.  It  frequently  serves  as  a  channel  for  the 
spread  of  malignant  tumours  situated  in  the 
upper  part  of  the  abdomen.  Enlargement  of 
the  inferior  deep  cervical  glands  in  the  left  side 
of  the  neck  may  be  the  first  sign  of  cancer  of  the 
stomach  (W.   M.    Stevens). 


CHAPTER    XIX 

THE    PELVIS 

Mechanism  of  the  pelvis. — Besides  forming 
a  cavity  for  certain  viscera,  a  support  for  some 
abdominal  organs,  and  a  point  for  the  attach- 
ment of  the  lower  limb  and  of  many  muscles, 
the  pelvis  serves  to  transmit  the  weight  of  the 
body  both  in  the  standing  and  sitting  postures. 
The  transmission  is  effected  through  two  arches, 
one  available  for  the  erect  position,  the  other  for 
the  posture  when  sitting.  When  standing,  the 
arch  is  represented  by  the  sacrum,  the  sacro-iliac 
synchondroses,  the  acetabula,  and  the  masses  of 
bone  extending  between  the  two  last-named  points. 
If  all  other  parts  of  the  pelvis  were  to  be  cut 
away  but  these,  the  portions  left  would  still  be 
able  to  support  the  weight  of  the  body,  and  would 
represent  in  its  simplicity  the  arch  through  which 
that  weight  is  transmitted.  When  sitting,  the  arch 
is  represented  by  the  sacrum,  the  sacro-iliac  syn- 
chondroses, the  tubera  ischii,  and  the  strong 
masses  of  bone  that  extend  between  the  two  last- 
named  parts.  Sir  Henry  Morris  terms  these  two 
arches  the  femoro-sacral  and  the  ischio-sacral.  On 
examining  the  innominate  bone  it  will  be  seen  that 
its  thickest  and  strongest  parts  are  such  as  are 
situate  in  the  line  of  these.  "  When  very  consider- 
able strength  is  requisite  in  an  arch,  it  is  continued 
into  a  ring  so  as  to  form  a  counter-arch,  or  what 
is  called  a  tie  is  made  to  connect  together  the 
ends  of  the  arch,  and  thus  to  prevent  them  from 
445 


446         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

starting  outwards.  By  these  means  a  portion  of 
the  superincumbent  weight  is  conveyed  to  the 
centre  of  the  counter-arch,  and  borne  in  what  is 
called  the  sine  of  the  arch.  The  body  and  hori- 
zontal rami  of  the  pubes  form  the  tie  or  counter- 
arch  of  the  femoro-sacral,  and  the  united  rami  of 
the  pubes  and  ischium  the  tie  of  the  ischio-sacral 
arch.  Thus  the  ties  of  both  arches  are  united  in 
front  at  the  symphysis  pubis,  which,  like  the 
sacrum  or  keystone,  is  common  to  both  arches. 
.  .  .  .  This  explains  how  it  is  that  so  much 
strain  is  made  upon  the  symphysis  when  any 
increased  weight  has  to  be  supported  by  the  pelvis, 
as  in  pregnancy ;  why  there  is  such  powerlessness, 
with  inability  to  stand  or  sit,  in  cases  in  which 
this  joint  is  weakened  or  diseased;  and  why  the 
anterior  portion  of  the  pelvis  yields  under  the 
weight  of  the  body  and  becomes  deformed  in 
rickets  and  mollities  ossium.;;  *  The  pelvic  de- 
formity in  rickets,  it  may  be  here  observed,  varies 
greatly  according  to  the  age  at  which  the  disease 
sets  in,  and  the  usual  attitude  of  the  child  when 
it  becomes  affected.  The  deformity  sometimes  pro- 
duced in  very  young  infants  has  been  ascribed 
to  muscular  contraction  (ilio-psoas,  erector  spinse, 
gluteus  medius,  etc.).  In  the  rickety  pelvis,  par 
excellence^  the  two  acetabula  approach  one  an- 
other, the  anterior  part  of  the  pelvis  yields,  so  that 
the  symphysis  is  pushed  forward,  and  the  cavity 
becomes  greatly  narrowed  in  its  transverse  diameter. 
In  severe  cases  the  anterior  arch  may  practically 
collapse,  and  the  horizontal  rami  of  the  pubes  be 
for  some  little  way  parallel  to  one  another. 

In  the  erect  attitude  the  pelvis  is  so  inclined 
that  the  plane  of  the  brim  of  the  true  pelvis  forms 
with  the  horizon  an  angle  of  from  60°  to  65°;  the 
base  of  the  sacrum  is  about  3|  inches  above  the 
upper  border  of  the  symphysis,  while  the  tip  of 
the  coccyx  is  a  little  higher  than  its  lower  border. 
The  centre  of  gravity  of  the  whole  body  (adult) 

*  Sir  Henry  Morris,    "  The  Joints,"  p.    11(3,    where  a  most  valuable 
account  of  the  mechanism  of  the  pelvis  will  be  found. 


XIX1  FKACTURES    OF    PELVIS  447 

is  at  a  spot  just  above  the  sacro-lumbar  angle, 
and  exactly  over  the  mid-point  of  a  line  drawn 
between  the  heads  of  the  femora. 

Fractures  of*  the  pelvis. — From  what  has 
been  already  said,  it  may  be  surmised  that  the 
weakest  parts  of  the  pelvis  are  at  the  symphysis 
and  the  sacro-iliac  joints.  The  bones  of  these 
parts,  however,  are  so  very  firmly  knit  together 
by  powerful  ligaments  that  it  is  very  rare  for 
these  articulations  to  give  way,  fracture  of  the 
adjacent  bones  being  more  common.  The  com- 
monest fracture  of  the  pelvis  is  in  the  weak 
counter-arch,  and  involves  the  rami  of  both  the 
pubes  and  the  ischium.  The  fracture  is  often 
associated  with  some  tearing  of  ligaments  about 
the  sacro-iliac  synchondrosis,  and  is  met  with  in 
accidents  due  to  the  most  varied  forms  of  vio- 
lence. This  last  remarkable  circumstance  is  thus 
explained  by  Tillaux.  If  the  pelvis  be  compressed 
in  (a)  an  antero-posterior  direction,  the  main 
brunt  of  the  force  comes  upon  the  weak  counter- 
arch,  which  fractures  from  direct  violence.  The 
force,  continuing,  tends  to  push  asunder  the  two 
iliac  bones,  and  so  cause  rupture  of  the  anterior 
ligaments  at  the  sacro-iliac  joint.  If  the  force  be 
applied  (b)  transversely,  the  two  acetabula  tend 
to  be  pressed  towards  one  another,  the  counter - 
arch  becomes  more  bent,  and  ultimately  gives  way 
by  indirect  violence.  The  violence,  continuing, 
forces  the  two  ilia  towards  one  another,  the  strain 
then  falls  upon  the  sacro-iliac  synchondrosis,  and 
the  posterior  ligaments  of  that  joint  are  apt  to 
yield,  or  portions  of  the  bone  adjacent  to  the  joint 
are  torn  away.  In  cases  of  falls,  when  the  patient 
alights  upon  the  feet  or  ischial  tuberosities,  it 
can  be  understood  how  in  many  instances  the  main 
arches  will  escape  injury  owing  to  their  great 
strength,  while  the  counter-arch  becomes  frac- 
tured. Any  part  of  the  pelvis,  including  the 
sacrum,  may  be  broken  by  well-localized  direct 
violence.  More  or  less  of  the  iliac  crest,  the  an- 
terior   superior    and    posterior    superior    spines, 


448         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

have  been  knocked  off.  The  first-named  part  may 
be  separated  as  an  epiphysis.  It  joins  the  bone 
at  about  the  twenty-fourth  year.  In  one  case  the 
anterior  inferior  spinous  process  was  torn  off  by 
the  rectus  muscle  during  the  act  of  running  a 
race.  The  os  innominatum  has  been  broken  into 
its  three  anatomical  portions.  This  accident  can- 
not take  place  after  about  the  seventeenth  year, 
since  by  that  time  the  Y-shaped  cartilage  is 
usually  fully  ossified,  and  the  three  elementary 
bones  are  fully  united.  Before  such  consolidation 
occurs,  abscess  in  the  hip-joint  not  unfrequently 
makes  its  way  through  the  cartilage  into  the 
pelvis.  The  acetabulum  has  been  fractured,  and 
the  head  of  the  femur  driven  through  its  thinnest 
part  into  the  pelvis.  In  fractures  of  the  pubes 
and  ischium  the  bladder  has  been  torn  by  the 
sharp  fragments.  In  one  case  a  loose  piece  of 
bone  that  had  been  driven  into  the  bladder  became 
the  nucleus  for  a  stone.  The  urethra  and  vagina 
also  have  been  lacerated  or  seriously  compressed 
by  the  displaced  bones.  In  fractures  of  the  sacrum 
the  rectum  has  been  torn,  or  has  been  so  compressed 
by  the  lower  fragment  (which  is  almost  always 
carried  forwards)  as  to  be  nearly  closed. 

Symphysis. — Separation  of  the  bones  at  the 
symphysis  without  fracture  has  occurred  from 
severe  violence.  Malgaigne  reports  three  cases 
where  the  separation  was  brought  about  by  mus- 
cular violence  only,  by  extreme  action  of  the 
adductor  muscles  of  the  two  sides.  The  Sigaultean 
operation  consisted  in  dividing  the  symphysis 
pubis  in  cases  of  contracted  pelvis,  with  the  idea 
of  obtaining  more  room  during  labour,  and  of 
so  avoiding  Caesarian  section.  The  union  consists 
of  fibro-cartilage  and  transverse  peripheral  fibrous 
bands.  It  varies  in  depth  from  lj  to  If  inches, 
and  may  be  divided  subcutaneously,  when  the 
bones  gape  quite  J  an  inch.  It  has  been  shown, 
however,  that  to  gain  J  an  inch  in  the  antero- 
posterior diameter  the  bones  must  be  separated  to 
the  extent  of  2  inches.     Such  a  separation  involves 


XIX]  SACRO-ILIAC    SYNCHONDROSIS  449 

laceration  of  the  sacro-iliac  ligaments,  and  more  or 
less  damage  to  the  attachments  of  the  pelvic  viscera. 
The  sacro-iliac   synchondrosis  may  be  the 

seat  of  disease.  Normally,  there  is  a  synovial 
space  and  a  slight  degree  of  movement  in  this 
joint.  As  the  articulation  lies  in  the  line  of 
the  great  arches  of  the  _  pelvis,  it  follows  that, 
when  inflamed,  much  pain  is  felt,  both  when  the 
patient  is  standing  and  when  sitting.  When 
abscess  forms  ifc  tends  to  come  forwards,  owing  to 
the  anterior  ligaments  being  slight  while  the  pos- 
terior ligament  is  dense,  thick,  and  of  great 
strength.  Having  reached  the  pelvic  aspect  of  the 
joint,  the  pus  may  occupy  the  iliac  fossa,  or  gain 
the  ilio-psoas  sheath.  Or  it  may  follow  the  lumbo- 
sacral cord  and  great  sciatic  nerve  and  point  in 
the  thigh  behind  the  great  trochanter,  or  it  may 
be  guided  by  the  obturator  vessels  to  the  inner  side 
of  the  thyroid  foramen,  and  ultimately  appear  at 
the  inner  side  of  the  thigh.  The  abscess  may, 
however,  proceed  backwards,  and  point  over  the 
posterior  aspect  of  the  joint. 

The  nerve  relations  of  this  joint  are  important. 
It  is  supplied  by  the  superior  gluteal,  by  the 
lumbo-sacral  cord  and  the  first  sacral  nerve,  and 
by  the  first  and  second  posterior  sacral  nerves 
(Morris).  The  lumbo-sacral  cord  and  the  obtura- 
tor nerve  pass  over  the  front  of  the  joint,  the 
former  being  very  closely  connected  with  the 
articulation.  It  will  be  understood  from  these 
relations  that  in  sacro-iliac  disease  pain  is 
felt  over  the  sacral  region  (upper  sacral  nerves) 
and  in  the  buttock  (gluteal  nerve).  Much  pain 
is  also  often  complained  of  in  the  hip-  or  knee- 
joint,  and  along  the  inner  part  of  the  thigh 
(obturator  nerve).  In  one#  or  two  reported  cases 
there  has  been  severe  pain  in  the  calf  and  back  of 
the  thigh,  with  painful  twitchings  in  the  muscles 
of  those  parts  (lumbo-sacral  cord  and  connexion 
with  the  great  sciatic  nerve.  Dislocation  of  the 
sacrum  at  this  joint  is  prevented  by  the  remark- 
able double  wedge-shaped  outline  of  the  bone,  and 


450         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

by  the  very  dense  ligaments  that  bind  it  in  its 
place.  The  bone  is  set  very  obliquely,  so  that 
the  weight  of  the  body  tends  to  force  its  base  into 
the  pelvis  and  tilt  its  apex  upwards.  The  strong 
posterior  sacro-iliac  ligaments  prevent  the  first 
movement,  the  great  sacro-sciatic  the  second. 

Trendelenburg's  operation, — In  order  to  bring 
the  two  pubic  bones  and  the  deficient  soft  parts 
together  in  ectopia  vesicae,  Trendelenburg  divides 
the  sacro-iliac  synchondroses  on  either  side.  The 
operation  is  limited  to  children  between  the  ages 
of  2  and  5.  The  distance  between  the  anterior 
superior  iliac  spines  has,  in  a  child  aged  2j 
years,  been  lessened  2  inches  by  this  operation. 

Sacro  -  coccygeal  tumours.  —  The  sacro- 
coccygeal region  is  very  often  the  seat  of  congenital 
tumours,  some  of  them  of  such  a  shape  as  to  form 
u  human  tails ";  and  to  this  part  of  the  pelvis 
has  also  been  found  attached  a  third  lower  limb 
leading  to  the  condition  known  as  "tripodism." 

Parasitic  foetuses  are  also  frequently  found 
attached  to  this  segment  of  the  spine.  In  many 
of  the  instances  of  attached  foetuses  the  two 
individuals  have  been  joined  together  at  this 
part  of  the  column.  Some  of  the  sacro-coccygeal 
tumours  contain  epithelial  cysts  and  fragments  of 
skin,  muscle,  nerve,  bone,  cartilage,  and  mucous 
membrane.  These  strange  masses  spring  from  the 
anterior  part  of  the  coccyx,  between  it  and  the 
rectum.  By  some  they  are  supposed  to  arise  from 
the  coccygeal  body,  by  others  (Sutton)  from  the 
structures  known  to  embryologists  as  the  post- 
anal gut  and  the  neurenteric  passage. 

The  sacro-coccygeal  joint  may  be  dislocated 
or  diseased.  In  either  affection  great  pain  is  kept 
up  from  the  frequent  movement  of  the  part  by  the 
muscles  attached  to  the  coccyx  (the  gluteus  maxi- 
mus,  coccygeus,  levator  ani,  and  sphincter).  In 
the  luxation  the  bone  may  project  into  the  rectum, 
and  thus  give  trouble.  The  joint  and  the  parts 
about  it  may  be  the  seat  of  such  severe  neuralgia 
("coccygodynia")   as  to   require  excision  of  the 


XIX]  PELVIC    FLOOR  451 

coccyx,  or  a  free  division  of  the  structures  that 
cover  it  behind.  The  joint  and  the  fibrous  tissue 
about  it  are  supplied  by  the  following  nerves  :  the 
posterior  divisions  of  the  second,  third,  and 
fourth  sacral,  and  the  anterior  and  posterior 
divisions  of  the  fifth  sacral  and  coccygeal.  In  old 
age  the  coccyx  becomes  ossified  to  the  sacrum. 

Floor  of  the  pelvis  and  the  pelvic 
fascia.  —  The  outlet  of  the  bony  pelvis  is  occu- 
pied in  the  recent  state  by  the  following  struc- 
tures, from  behind  forwards  :  the  pyriformis,  the 
sacro-sciatic  ligaments,  the  coccygeus,  the  levator 
ani,  and  the  triangular  ligament  of  the  perineum. 
These  form  the  floor  of  the  pelvis.  The  three 
structures  last  named  serve  to  separate  the  pelvic 
cavity  from  the  perineum  and  provide  a  ham- 
mock-like support  for  the  viscera  of  the  pelvis. 

Aperture  of  pelvic  floor. — The  pubo-rectal  fibres 
of  the  right  and  left  levator  ani  are  separated 
by  a  narrow  aperture  or  cleft  which  extends  from 
the  symphysis  pubis  to  the  ano-coccygeal  body. 
Through  it  pass  the  anal  canal,  the  vagina,  and 
the  urethra.  In  parturition  it  becomes  greatly 
distended  by  the  passage  of  the  foetal  head,  and  it 
is  also  relaxed  and  elongated  during  defsecation. 
Its  length  is  about  If  inches;  in  defecation  the 
fibres  are  relaxed  and  the  anal  canal  moves  back- 
wards and  downwards  so  that  the  aperture  is 
elongated  about  i  an  inch  (R.  H.  Paramore).  In 
muscular  efforts,  #  when  the  musculature  of  the 
abdominal  wall  is  also  contracted,  the  aperture 
is  shortened  by  the  contraction  of  the  pubo-rectal 
fibres,  the  anal  canal  being  pulled  towards  the 
symphysis.  The  aperture  is  also  filled,  between 
the  anal  canal  and  the  uro-genital  passage,  by  the 
perineal  body:  the  part  between  the  adjacent 
borders  of  the  aperture  contains  non-striated 
muscular  tissue.  Anteriorly  the  (  aperture  is 
strengthened  by  the  triangular  ligament ;  the 
mesial  pubo-rectal  fibres  lie  on  this  ligament. 

Pelvic  fascia. — The  pelvic  fascia  is  a  complex 
structure   made   up   of   the   following   parts  :    (1) 


452         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

Muscular  sheaths ;  (2)  visceral  sheaths  or  capsules  ; 
(3)    vascular    sheaths;    (4)    arcuate    ligament    of 
the  levator   ani.      The   muscular  sheaths  are  the 
following  :  (1)  The  obturator  fascia,  which  covers 
the  pelvic  aspect  of  the  obturator   internus  and 
is   attached  to  the   interior   of  the   pelvis  round 
the   origin   of   the   muscle;    (2)    the   fibrous   sheet 
on  the  pelvic  aspect  of  the  pyriformis,  in  which 
are  embedded  the  internal  iliac  vessels  and  sacral 
nerves;    (3)    the    sheath   of   the    levator    ani — the 
layer    on    its    perineal    aspect    is    known    as    the 
anal  fascia,  the  stratum  on  its  pelvic  aspect  as 
the   visceral  layer   of   fascia;    (4)   the   triangular 
ligament,  which  is  the  fibrous  tissue  enclosing  the 
constrictor  urethrse  and  affording  a  firm  attach- 
ment  to   the   bulb    of   the   penis    (Elliot    Smith). 
The  visceral  sheaths  are  :    (l)  the  capsule  of  the 
prostate;    (2)   the   sheath  of  the   vagina;    (3)   the 
sheath .  of    the    rectum.      These    fibrous   coverings 
fuse  with  the  visceral  layer  on  the  upper  surface 
of    the    levator    ani    and    with    the    perivascular 
sheaths.      The   perivascular  sheaths   are  :    (l)   the 
fibrous  tissue   surrounding  the   visceral  branches 
of  the  internal  iliac  artery — the  uterine,  vesical, 
prostatic,     and    hemorrhoidal  —  and^    round    the 
pelvic  plexus  of  nerves  (part  of  this  tissue  has 
been  described  under  the  name  of  the  suspensory 
ligament  of  the  pelvic  viscera — A.  M.   Paterson)  ; 
(2)   the   fibrous   sheath   surrounding  the   internal 
pudic  vessels,  of  which  Alcock's  canal  is  a^  part. 
The    arcuate    tendon    of    the    levator    ani    is    the 
structure   formerly    described    as   the   white   line. 
It    is    a    strong    band    of    fibrous    tissue    passing 
backwards  from  the  posterior  aspect  of  the  pubis, 
near  the  lower  border   of  the  symphysis,   to  the 
inner  aspect  of  the  pelvis,  near  the  ischial  spine 
on    the    inner    surface    of    the    obturator    fascia. 
From    this    tendinous    band    many    fibres    of    the 
levator  ani  arise ;  the  suspensorv  or  perivascular 
ligament  is  also  supported  from  it.   Its  middle  part 
is  often  free,  so  that  one  can  slip  a  finger  down- 
wards between  the  arcuate  ligament  and  the  obtur- 


XIX]  FIXATION    OF    PELVIC    VISCERA  453 

ator  fascia ;  a  hernia  may  occur  here.  The  muscular 
and  vascular  sheaths  unite  at  their  points  of  con- 
tact, and  thus  the  pelvic  diaphragm  and  viscera  are 
welded  together  to  form  a  united  complex  structure. 
Fixation  and  movements  of  the  pelvic 
viscera. — The  pelvic  viscera  are  liable  to  dis- 
placement; a  knowledge  of  how  they  are  fixed 
and  kept  in  position  affords  the  only  basis  of  a 
sound  treatment.  The  bladder,  rectum,  and 
uterus  must  be  so  lodged  that  they  may  fill  and 
empty;  they  must  be  so  supported  that  they  can 
withstand  the  violent  movements  and  pressures 
to  which  all  the  abdominal  viscera  are  subject 
during  active  muscular  and  respiratory  efforts. 
To  allow  a  free  visceral  movement,  the  parietal 
pelvic  peritoneum  is  loosely  attached,  but  over 
the  bladder,  uterus,  and  rectum  this  membrane 
is  firmly  bound  down.  Thus,  when  these  viscera 
are  distended,  the  reflections  of  the  parietal  peri- 
toneum, being  attached  by  an  extremely  lax  layer 
of  subserous  tissue,  readily  allow  the  viscera  to 
expand  and  mount  up  from  the  pelvis.  When 
their  contents  are  being  expelled,  the  visceral  mus- 
culature requires  a  fixed  point  from  which  to  act. 
The  musculature  of  the  bladder  is  fixed  to  the 
back  of  the  pubis  and  triangular  ligament  by 
the  pubo-prostatic  ligament  and  capsule  of  the 
prostate;  it  is  also  attached  to  the  anterior 
parts  of  the  arcuate  ligaments  of  the  levator 
ani  by  the  lateral  true  vesical  ligaments.  The 
vagina,  which  is  also  attached  to  the  arcuate  and 
triangular  ligaments,  affords  an  indirect  attach- 
ment of  the  uterus  to  the  pelvis  during  parturi- 
tion. The  anal  canal  is  fixed  in  the  posterior 
part  of  the  aperture  of  the  pelvic  floor.  The 
rectum  becomes  continuous  with  the  anal  canal ; 
anterior  bands^  of  its  longitudinal  muscular  coat 
end  in  the  perineal  body.  The  rectum  is  further 
fixed  bv  its  sheath  becoming  continuous  with  the 
upper  layer  of  visceral  fascia  on  the  levator  ani, 
and  to  the  sacrum  and  coccyx.  This  layer  of 
visceral  fascia  and  also  the  perivascular  or  sus- 


454         THE    ABDOMEN    AND    THE    PELVIS 

pensory  ligaments  help  to  support  the  pelvic 
viscera  in  the  following  manner  :  Above,  they 
are  attached  to  the  lateral  pelvic  wall  by  the 
fibrous  ligament  of  the  levator  ani;  below,  they 
blend  with  the  sheaths  of  the  prostate,  vagina, 
and  rectum.  When  the  viscera  are  in  their  normal 
position  and  the  levatores  ani  are  in  action, 
these  ligamentous  supports  are  slack;  it  is  only 
when  the  muscular  support  of  the  pelvic  diaphragm 
is  withdrawn  and  the  viscera  are  displaced  that 
these  ligamentous  supports  come  into  action.  In 
violent  movements  of  the  pelvic  viscera  their  nerves 
and  vessels  would  be  subject  to  strain  were  they 
not  protected  by  strong  sheaths.  The  condition 
is  the  same  as  the  support  of  the  shoulder-joint  : 
the  muscles  retain  the  bones  in  their  normal  posi- 
tion ;  the  ligaments  come  into  action  only  when 
the  limit  of  muscle  action  has  been  exceeded. 

Subserous  tissue  of  the  pelvis.— The  loose 
subserous  tissue  which  attaches  the  peritoneum 
to  the  pelvic  fascia  is  often  the  seat  of  in- 
flammatory processes,  especially  in  the  female. 
Between  the  broad  ligaments,  round  the  neck  of 
the  uterus  and  by  the  sides  of  the  vagina  it  is 
particularly  abundant,  and  forms  the  perimetric 
and  parametric  tissue.  It  allows  a  free  mobility 
to  the  vagina  and  uterus.  Inflammatory  processes 
and  abscesses  may  spread  rapidly  up  the  sides  of 
the  pelvis  and  into  the  iliac  fossae,  through  the 
subserous  stratum  of  connective  tissue.  In  this 
stratum,  too,  lie  the  ureter  and  the  iliac  vessels, 
surrounded  by  their  fibrous  sheaths.  In  this 
layer  are  also  the  fibro-muscular  bands  which 
form  the  utero-sacral  and  round  ligaments.  The 
utero-sacral  ligaments  encircle  the  pouch  of 
Douglas  and  bind  the  upper  part  of  the  vagina 
to  the  loose  tissue  of  the  sacrum.  The  fold  of 
peritoneum  at  the  bottom  of  the  recto-vesical  or 
recto-vaginal  pouch  is  fixed  to  the  sheath  of  the 
prostate  or  vagina  and  to  the  perineal  body  by 
a  septum  of  fibrous  tissue  which  separates  the 
rectum  from  the  structures  anterior  to  it. 

Nerves  of  the  pelvis.     (See  p.  499.) 


CHAPTER   XX 

THE     PERINEUM 

Male  perineum  (Fig.  92). — This  is  a  lozenge- 
shaped  space  bounded  by  the  symphysis,  the  rami 
of  the  pubes  and  the  ischia,  the  ischial  tuber- 
osities, the  great  sacro-sciatic  ligaments,  the 
edges  of  the  two  great  gluteal  muscles,  and  the 
coccyx.  A  transverse  line  drawn  across  the  space 
between  the  anterior  extremities  of  the  tubera 
ischii,  and  just  in  front  of  the  anus,  divides  the 
perineum  into  two  parts.  The  anterior  part 
forms  nearly  an  equilateral  triangle,  measuring 
about  3j  inches  on  all  sides.  It  is  called  the 
urethral  triangle.  The  posterior  part  is  also 
somewhat  triangular,  contains  the  rectum  and 
ischio-rectal  fossae,  and  is  called  the  anal  triangle. 
The  whole  space  measures  about  3j  inches  from 
side  to  side,  and  about  4  inches  from  before  back- 
wards in  the  middle  line.  The  average  antero- 
posterior diameter  of  the  pelvic  outlet  in  the  male 
averages  3j  inches.  This  measurement  in  the  un- 
dissected  subject  is  increased  to  4  inches  by  the 
curving  of  the  surface.  The  average  transverse 
diameter  of  the  male  pelvic  outlet  is  3j  inches, 
and  corresponds  to  the  measurement  of  the  peri- 
neum above  given. 

The  bony  framework  of  the  perineum  can  be 
felt  more  or  less  distinctly  all  round,  and  in  thin 
subjects  the  great  sacro-sciatic  ligaments  can  be 
made  out  beneath  the  great  gluteal  muscle.  The 
anus  is  in  the  middle  line  between  the  ischial 
455 


_ 


456         THE    ABDOMEN    AND    THE    PELVIS     [Chap, 

tuberosities,  its  centre  being  about  if  inches  from 
the  tip  of  the  coccyx.  The  raphe,  a  central  mark 
or  ridge  in  the  skin,  can  be  followed  from  the  anus 


Fig.  92. — The  male  perineum.      (After  Rildinger.) 

a,  Gluteus  maximus ;  b,  semi-tendinosus  and  biceps  ;  c,  adductor 
magnus  ;  d,  gracilis  ;  e,  pyrif ormis  ;  /,  obturator  internus  ;  g,  quad- 
ratus  f emoris  ;  h,  levator  ani ;  i,  external  sphincter  ;  j,  accelerator 
urinae  ;  k,  erector  penis ;  I,  transversus  perinei ;  1,  great  sciatic 
nerve  ;  2,  external  haemorrhoidal  vessels  and  nerve  ;  3,  superficial 
perineal  vessels  and  nerves;  4,  pudic  nerve  (cut)  and  pudic 
artery  ;  5,  pudendal  branch  of  small  sciatic  nerve. 

along  the  middle  line  of  the  perineum,  scrotum, 
and  penis.  No  vessels  cross  this  line,  and,  there- 
fore,  in  making  incisions  into  the  perineum  the 


XX]  ISCHIO-KECTAL    FOSSA  457 

line  is  always  chosen  when  possible.  In  the  middle 
line,  midway  between  the  centre  of  the  anus  and 
the  spot  where  the  scrotum  joins  the  perineum,  is 
the  central  point  of  the  perineum.  The  two  trans- 
verse perineal  muscles,  the  accelerator  urinse  and 
the  sphincter  ani,  meet  at  this  point,  which  also 
corresponds  to  the  centre  of  the  inferior  edge  of 
the  triangular  ligament.  The  bulb  is  just  in 
front  of  it,  as  is  also  the  artery  to  the  bulb,  and 
in  lithotomy,  therefore,  the  incision  should  never 
commence  in  front  of  this  spot. 

The  perineal  space  is  separated  from  the  pelvic 
cavity  by  the  levator  ani  muscles  and  the  fascial 
structures  connected  with  them.  The  depth  oi  the 
perineum  means  the  distance  between  the  skin  and 
the  pelvic  floor.  This  depth  depends,  to  a  great 
extent,  upon  the  amount  of  fat  under  the  integu- 
ment. It  varies  considerably  in  different  parts, 
measuring  from  2  to  3  inches  in  the  hinder  and 
outer  parts  of  the  perineum,  and  less  than  1  inch 
in  the  anterior  parts  of  the  space. 

The  ischio-rectal  fossa  is  of  pyramidal 
shape,  its  apex  being  at  the  lower  border  of  the 
levator  ani  (see  Fig.  93),  and  its  base  being 
formed  by  the  skin  between  the  anus  and  the 
ischial  tuberosity.  The  fossa  is  shut  in  at  its 
apex  by  the  fusion  of  the  fibrous  layers  on  the 
outer  and  inner  wall.  It  becomes  shallower  as 
it  passes  forwards,  and  ceases  opposite  the  base 
of  t  the  triangular  ligament.  It  measures  about 
2  inches  from  before  back,  1  inch  from  side  to 
side,  and  is  between  2  and  3  inches  in  depth.  Its 
boundaries  are  :  on  the  outer  side,  the  obturator 
internus  muscle,  covered  by  its  fascia  and  the 
fibrous  sheath  of  the  internal  pudic  vessels  and 
nerves  (Fig.  93) ;  on  the  inner  side,  the  anal 
canal,  covered  by  the  anal  fascia;  in  front,  the 
base  of  the  triangular  ligament  and  the  trans- 
versus  perinei  muscle;  and  behind,  the  gluteus 
maximus,  great  jsacro-sciatic  ligament,  and  coccy- 
geus.  The  pudic  vessels  and  nerves  are  placed 
about    \\    inches    above   the   lower   border    of   the 


458         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

tuber  ischii.  ■  The  fossa  is  occupied  by  a  mass  of 
fat  which  affords  to  the  anal  canal  the  support 
of  an  elastic  cushion.  This  fatty  tissue  is  badly 
supplied  with  blood,  and  this  fact,  in  addition 
to  the  dependent  situation  of  the  part,  and  its 
exposure  when  the  patient  sits  upon  damp,  cold 
seats,  etc.,  leads  to  abscess  being  very  frequent 
in  the  space  (ischio= rectal  abscess).  These  ab- 
scesses are  hemmed  in  on  all  sides,   soon  fill  the 


Long.  Coat     Obt.  Int.     Ischium 
Circ.  Coat 


Anal  Valves 
Anal  Canal 


pudic  Vessels 
Semitendinosus 

Ischio-Rectal  Fossp 
Levator  Ani 
Glut.   Medius 


Fig.  93. — Section  of  the  anal  canal  and  of  the  ischio-rectal 
space.  (Modified  from  figures  by  Prof.  Elliot  Smith  and 
Sir  Charles  Ball ) 


fossa,  and  then  tend  to  discharge  themselves  in 
the  two  directions  where  the  resistance  is  least, 
viz.  through  the  skin  and  through  the  wall  of  the 
anal  canal.  When  this  double  discharge  of  the 
abscess  has  taken  place,  a  complete  fistula  in 
ano  is  established.  It  is  well  to  note  that  in 
fistulse  in  ano  the  opening  into  the  anal  canal  is 
nearly  always  within  i  an  inch  of  the  anus.  An 
opening  into  the  bowel  higher  up  is  resisted  by 
the  union  of  the  fibrous  covering  of  its  outer 
and  inner  wall   (Fig.   93). 


XX]  URETHRAL    TRIANGLE  459 

Crossing  the  space  obliquely  from  its  hinder 
part  to  the  anus  are  the  external  hemorrhoidal 
vessels  and  nerves  (Fig.  92) ;  crossing  the  an- 
terior and  outer  corner  of  the  fossa  are  the 
perineal  vessels  and  nerves,  and  about  the  pos- 
terior border  of  the  space  are  the  fourth  sacral 
nerve  and  some  branches  of  the  small  sciatic 
nerve.  It  will  be  readily  understood,  therefore, 
that  ischio-rectal  abscesses  are  associated  usually 
with  extreme  suffering  until  they  are  relieved. 
The  severe  pain  is  probably  due  to  the  rich 
nerve  supply  of  the  skin  and  mucous  membrane 
of  the  anus,  and  also  to  the  stretching  of  the 
external  hemorrhoidal  nerve  by  the  abscess  as 
it  progresses  towards  the  surface.  In  opening 
an  abscess  in  the  fossa  the  main  structures  to 
avoid  are^  the  rectum,  the  pudic  and  external 
hemorrhoidal  vessels. 

Anus.     (See  p.   497.) 

Urethral  triangle.  —  The  skin  of  the  peri- 
neum between  the  anus  and  the  scrotum  is  thin, 
and  shows  very  readily  any  extravasations  of 
blood  that  may  form  beneath  it.  The  superficial 
fascia  is  divided  into  two  layers,  of  which  the 
more  superficial  is  quite  unimportant,  and  con- 
tains what  little  subcutaneous  fat  exists  in  this 
part. 

The  deep  layer,  known  as  the  perineal  fascia  or 
fascia  of  Colles,  is  attached  on  either  side  to  the 
rami  of  the  pubes  and  ischium,  and  behind  to 
the  base  of  the  triangular  ligament.  In  front  it 
becomes  continuous  with  the  dartos  tissue.  This 
fascia,  therefore,  by  its  attachments  forms  with 
the#  triangular  ligament  a  well-isolated  aponeu- 
rotic space,  containing  the  bulb  with  all  that  part 
of  the  spongy  urethra  between  the  triangular 
ligament  and  the  attachment  of  the  scrotum,  the 
penile  muscles,  the  transverse  perineal  muscles, 
vessels,  and  nerves,  and  the  perineal  vessels  and 
nerves.  When  extravasation  of  urine  follows 
upon  a  rupture  of  the  part  of  the  urethra  above 
named,  the  course  of  the  escaping  fluid  is  directed 


460         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

by  the  fascia  of  Colles.  It  fills  the  aponeurotic 
space.  It  is  unable  to  gain  the  ischio-rectal  fossa 
on  account  of  the  attachment  of  the  fascia  to  the 
triangular  ligament.  The  lateral  attachments  of 
this  membrane  prevent  the  urine  from  passing 
into  the  thighs.  It  is  therefore  guided  into  the 
scrotum,  and  there  finds  itself  beneath  the  dartos 
tissue.  It  distends  the  scrotal  tissues,  and  then 
mounts  up  on  to  the  abdomen  through  the  gap 
left  between  the  symphysis  pubis  and  pubic  spine. 
It  must  be  remembered  that  the  fascia  of  Colles, 
the  dartos  tissue,  and  the  deeper  layer  of  the 
superficial  fascia  of  the  abdomen  are  continuous, 
and  merely  represent  different  parts  of  the  same 
structure.  Pus  or  blood  within  this  aponeurotic 
space  would  follow  the  same  course  if  the  effusion 
were  extensive  enough.  The  pain  occasioned  by 
such  effusion  can  be  understood  when  it  is  noted 
that  the  three  chief  sensory  nerves  of  this  region 
(the  three  long  scrotal  nerves)  are  included  within 
the  space. 

The  triangular  ligament  has  a  depth  of 
about  lj  inches  in  the  middle  line,  and  is  formed 
of  two  layers,  of  which  the  posterior  is  thin, 
ill-defijied,  and  formed  by  the  sheath  on  the 
lower  surface  of  the  pubic  fibres  of  the  levator 
ani.  The  membranous  urethra,  surrounded  by  the 
compressor  urethrse,  lies  between  the  two  layers, 
and  runs  about  1  inch  below  the  symphysis,  and 
about  |  of  an  inch  above  the  central  point  of 
the  perineum  (Fig.  94).  The  artery  to  the  bulb 
passes  inwards  between  the  two  layers  about  J  an 
inch  above  the  base  of  the  ligament  and  lj  inches 
in  front  of  the  anus.  The  terminal  part  of  the 
pudic  artery  pierces  the  anterior  layer  of  the 
ligament  about  J  an  inch  below  the  symphysis. 
The  dorsal  vein  of  #the  penis  enters  the  pelvis 
between  the  subpubic  ligament  and  the  apical 
part  (transverse  part)  of  the  triangular  ligament ; 
the  dorsal  nerve  accompanies  it  (Elliot  Smith). 
In  uncomplicated  rupture  of  the  membranous 
urethra,  the  urine  extravasated  would  be  limited 


XX] 


THE    PEKINEUM 


461 


Rectum 

Vesicul/e 
■  Seminales 
.Transverse 
Fold 


Fossa 
Kiavicularis. 


Fig.  94. — Vertical    antero-posterior    section    of  the   male 
pelvis.       (Br  mine.) 


462         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

to  the  space  between  the  layers  of  the  ligament, 
until  subsequent  suppuration  had  made  a  way 
for  it  to  escape.  When  extravasation  occurs  be- 
hind the  triangular  ligament,  the  effusion  may 
collect  in  the  retropubic  space  if  the  capsule  of 
the  prostate  is  ruptured  (Deanesley),  or  it  may 
pass  backwards  by  the  side  of  the  rectum  into 
the  cellular  tissue  of  the  pelvis. 

Just  beyond  the  triangular  ligament  is  the 
prostate,  surrounded  by  its  capsule  and  the  pros- 
tatic venous  plexus  (Figs.  94  and  95).  In  dissecting 
down  from  the  surface  to  the  prostate,  we  meet,  as 
Cunningham  has  well  pointed  out,  alternate  strata 
of  fascial  and  muscular  tissue,  forming  seven 
layers  in  all,  viz.  :  (1)  superficial  fascia;  (2)  super- 
ficial perineal  muscles;  (3)  triangular  ligament 
(ant.  layer) ;  (4)  compressor  urethrse  muscle;  (5) 
triangular  ligament  (post,  layer) ;  (6)  levator  ani 
muscle;  (7)  sheath  of  prostate. 

Stone  in  the  bladder. — Stones  in  the  bladder, 
which  were  formerly  removed  by  a  perineal  in- 
cision, are  now  commonly  crushed  and  washed  out 
through  the  urethra  by  the  operation  of  litho- 
lapaxy.  This  operation  is  carried  out  readily 
even  in  male  children.  If  the  stones  are  too 
large  for  crushing,  the  suprapubic  operation  is 
performed  to  give  sufficient  room  for  extraction. 
Although  the  perineal  operations  are  now  but  very 
rarely  performed,  a  description  of  the  parts  in- 
volved helps  to  give  a  proper  conception  of  their 
important  anatomical  relationships. 

Lateral  lithotomy. — The  first  incision,  2  or 
3  inches  in  length,  is  commenced  just  to  the  left 
of  the  middle  line  and  just  behind  the  central 
point  of  the  perineum,  t  i.e.  .  about  1  \  inches  in 
front  of  the  anus.  The  incision  is  carried  down- 
wards and  outwards  into  the  left  ischio-rectal 
fossa,  and  ends  at  a  point  between  the  tuber  ischii 
and  posterior  part  of  the  anus,  and  one-third 
nearer  to  the  tuberosity  than  to  the  gut.  In  the 
early  part  of  this  incision  the  staff  may  just  be 
touched,  as  it  lies  in  the  membranous  urethra,  the 


XX]  LATERAL    LITHOTOMY  463 

incision  becoming  more  and  more  shallow  as  the 
knife  is  withdrawn.  The  parts  cut  in  the  first 
incision    are:     (1)    skin    and    superficial    fascia; 

(2)  transverse  perineal  muscle,  artery  and  nerve; 

(3)  the  lower  edge  of  the  anterior  layer  of  the 
triangular  ligament;  (4)  the  external  hemor- 
rhoidal vessel  and  nerves  (Figs.  92,  93  and  94). 

In  the  second  incision  the  knife,  guided  by  the 
forefinger  of  the  left  hand,  is  passed  upwards 
behind  the  triangular  ligament,  is  engaged  in  the 
groove  on  the  staff  as  it  lies  in  the  membranous 
urethra,  and  then,  having  its  edge  turned  towards 
the  left  tuber  ischii,  is  steadily  carried  along 
the  groove  into  the  bladder.  In  this  incision  the 
parts  divided  are  :  (1)  membranous  and  prostatic 
portions  of  urethra;  (2)  posterior  layer  of  tri- 
angular ligament ;  (3)  compressor  urethrse ;  (4) 
anterior  fibres  of  levator  ani  and  left  lateral  lobe 
of  prostate.  The  finger  is  then  introduced  along 
the  staff  into  the  bladder,  the  staff  is  removed, 
and,  the  forceps  being  inserted,  the  stone  is  ex- 
tracted, traction  being  made  in  the  proper  axis 
of  the  pelvis. 

Parts  that  may  be  wounded. — (a)  In  the  first 
incision  :  (1)  the  bulb,  or  the  artery  of  the  bulb. 
These  parts  can  be  avoided  by  commencing  the 
incision  well  behind  the  " central  point/'  and  by 
causing  the  holder  of  the  staff  to  draw  it,  the 
scrotum,  and  the  penis  well  up.  The  staff  should 
be  held  as  close  up  under  the  pubes  as  possible. 
The  bulb  is  very  small  in  children,  large  in 
adults,  and  largest  in  old  men.  (2)  The  rectum 
may  be  cut  if  much  distended,  or  if  the  incision 
be  made  too  vertical  or  carried  too  far  back.  In 
all  cases  the  gut  should  be  well  emptied  by  enema 
before  the  operation.  (3)  The  pudic  vessels  can 
hardly  be  wounded  unless  the  incision  is  very 
carelessly  made,  and  the  knife  carried  almost 
against  the  bone  as  it  is  being  withdrawn,  (b) 
In  the  second  incision  the  knife  may  be  passed 
beyond  the  prostate,  and  may  so  incise  the  vis- 
ceral layer  of  the  pelvic  fascia  as  to  open  up  the 


464         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

pelvic  cavity.  It  will  be  understood  that  the 
lateral  lobe  of  the  prostate  may  be  cut  freely 
without  this  cavity  being  endangered.  The  gland 
is  enveloped  by  the  pelvic  fascia,  but  the  incision 
made  into  the  prostate  is  well  below  the  superior 
reflection  of  the  membrane.  The  incision  in  the 
neck  of  the  bladder,  therefore,  must  be  strictly 
limited  to  the  prostate.  The  prostatic  plexus  of 
veins  cannot  avoid  being  wounded.  The  left 
ejaculatory  duct  would  be  cut  if  the  prostatic 
incision  were  carried  too  far  backwards. 

In  children  the  pelvis  is  relatively  narrower 
than  in  the  adult,  the  bladder  is  more  an  ab- 
dominal than  a  pelvic  organ,  and  the  neck  of  the 
bladder,  therefore,  is  high  up.  The  viscus,  more- 
over, is  very  movable,  and  has  less  substantial 
attachments  than  has  the  adult's  bladder.  It  thus 
happens  that,  in  forcing  the  finger  into  the  bladder 
after  the  second  incision,  the  viscus  has  actually 
been  torn  away  from  the  urethra.  In  children 
the  prostate  is  rudimentary,  and  thus  more  of 
the  actual  neck  of  the  bladder  itself  has  to  be 
cut.  From  the  small  size  of  this  gland,  it  hap- 
pens, too,  that  in  some  cases  the  knife  has  passed 
too  far  beyond  the  prostatic  area,  and  has  opened 
up  the  pelvic  fascia.  In  children  also  the  peri- 
toneum descends  lower  on  the  posterior  surface 
of  the  bladder,  and  may  be  wounded  by  a  careless 
operator. 

Median  lithotomy.— In  this^  operation  the  knife 
is  entered  in  the  middle  line,  just  in  front 
of  the  anus.  The  staff  has  a  central  groove,  and 
the  point  of  the  knife  should  hit  the  instrument 
as  near  as  possible  to  the  apex  of  the  prostate. 
As  the  knife  is  withdrawn  the  whole  of  the  mem- 
branous urethra  is  incised,  and:  a  wound  made  in 
the  median  raphe  of  about  lj  inches  in  length. 

Parts  divided, — (1)  Skin  and  superficial 
fascia ;  (2)  sphincter  ani ;  (3)  central  point  of 
perineum;  (4)  lower  border  of  triangular  liga- 
ment; (5)  whole  length  of  membranous  urethra; 
(G)  compressor  urethrse. 


XX]  LITHOTOMY  465 

In  lithotomy,  and  in  other  operations  for  reach- 
ing the  neck  of  the  bladder  through  the  perineum, 
it  should  be  remembered  that  the  bladder  lies  at 
a  depth  of  from  2j  to  3  inches  from  the  surface 
when  the  body  is  in  the  lithotomy  position  (Fig.  94). 
If  the  bladder  is  empty  and  the  rectum  full, 
the  prostate,  trigone  and  reflection  of  peritoneum 
are  carried  upwards  and  forwards;  if  the  bladder 
is  full  and  the  rectum  empty,  the  movement  is  in 
an  opposite  direction.  In  fat  people  the  bladder 
and  peritoneum  are  carried  away  from  the 
perineum;  in  lean  people  the  opposite  occurs. 

Suprapubic  lithotomy.  —  This  operation  has 
been  revived  of  late  years,  and  in  cases  in  which 
litholapaxy  is  contra-indicated  has  practically 
supplanted  the  two  forms  of  lithotomy  just  de- 
scribed. In  order  to  bring  the  summit  of  the 
bladder  well  above  the  symphysis,  both  bladder 
and  rectum  may  be  dilated.  Into  the  former  vis- 
cus,  tepid  water  or  boric  lotion  is  injected.  It 
is  found  that  in  the  adult  8  to  10  ounces  is  suffi- 
cient to  ensure  the  desired  distension.  The  rec- 
tum is  dilated  by  some  operators  by  means  of  a 
soft  rubber  bag.  The  gut,  when  thus  distended, 
pushes  forward  the  bladder,  and  gives  it  a  firm 
basis  upon  which  to  rest.  In  the  adult  from  10 
to  14  ounces  is  usually  introduced  into  the  bag. 
In  the  case  of  a  male  child,  aged  5,  the  injection 
of  3  ounces  of  water  into  the  bladder  caused  the 
reflection  of  peritoneum  to  mount  to  more  than 
1  inch  above  the  symphysis.  An  incision,  some  3 
inches  in  length,  is  made  immediately  above  the 
symphysis  in  the  median  line.  The  bladder  is 
exposed  below  the  peritoneum,  is  drawn  forwards 
by  a  hook,  and  opened. 

The  bladder. — When  empty  the  bladder  is 
flattened  and  of  triangular  outline,  and  lies 
against  the  anterior  wall  of  the  pelvis.  The 
empty  bladder  may  be  found  in  one  of  two  condi- 
tions (as  demonstrated  by  Dr.  Hart  in  the  adult 
female  bladder).  It  may  be  small,  oval,  and 
firm,    with    its    upper    wall    convex    towards    the 


466         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

abdomen.  In  vertical  anteroposterior  section  the 
urethra  forms  with  the  cavity  of  the  bladder  a 
curved  slit  (the  systolic  empty  bladder).  It  may 
be  larger,  and  soft,  with  its  upper  surface  con- 
cave towards  the  abdomen,  and  fitting  into  the 
concavity  of  the  lower  wall  or  surface.  In  the 
section  named,  the  urethra  forms,  with  the  blad- 
der cavity,  a  Y-shaped  figure,  the  two  diverging 
limbs  of  the  Y  corresponding  to  the  concavity 
named  (the  diastolic  empty  bladder).  When 
moderately  distended  with  an  opaque  solution 
and  examined  by  the  aid  of  X-rays  it  is  seen  to 
be  conical  in  form,  with  its  apex  behind  the  sym- 
physis and  its  base  or  upper  surface  indented 
by  the  pressure  of  the  abdominal  viscera  (Fig.  91, 
p.  439).  As  distension  of  the  bladder  increases, 
the  summit  of  the  viscus  is  brought  more  and  more 
in  contact  with  the  anterior  abdominal  wall,  the 
organ  becoming  also  more  convex  on  its  posterior 
than  on  its  anterior  surface.  This  tendency  for 
the  summit  of  the  distended  bladder  to  press  itself 
against  the  anterior  parietes  is  of  good  service  in 
tapping  the  organ  above  the  pubes,  and  in  supra- 
pubic lithotomy.  When  greatly  distended  it  may 
reach  the  umbilicus,  and  may  even  touch  the 
diaphragm.  The  usual  capacity  of  the  organ  is 
about  one  pint,  but  when  quite  full  it  may 
hold  some  quarts.  When  both  bladder  and  rec- 
tum are  quite  empty  the  apex  of  the  bladder  and 
the  prevesical  reflection  of  the  peritoneum  are  a 
little  below  the  upper  margin  of  the  symphysis 
pubis.  As  the  distended  bladder  ascends  above 
the  pubes  it  dissects  the  serous  membrane  from 
the  parietes,  and  the  layer  so  lifted  off  forms 
a  cul-de-sac  or  fold  of  peritoneum  between  the 
upper  part  of  the  anterior  surface  of  the  bladder 
and  the  parietes.  When  the  apex  of  the  bladder  is 
2  inches  above  the  pubes  the  peritoneal  reflection 
is  probably  not  more  than  |  of  an  inch  above 
the  same  point  of  bone.  When  the  apex  of  the 
bladder  is  midway  between  the  umbilicus  and 
the  pubes  there  may  be  2  inches  (vertical)  of  the 


XX]  THE    BLADDER  467 

anterior  abdominal  wall  in  the  middle  line  and 
immediately  above  the  symphysis  devoid  of  peri- 
toneal lining.  Thus  it  happens  that  the  distended 
viscus  may  be  readily  tapped  above  the  pubes 
without  the  peritoneum  being  wounded.  As  the 
bladder  becomes  distended,  not  only  does  it  rise 
into  the  abdomen,  but  it  extends  also  towards  the 
perineum,  diminishing  the  length  of  the  prostatic 
and  membranous  urethra. 

Between  the  anterior  surface  of  the  bladder 
and  the  symphysis,  and  shut  in  by  the  peritoneum 
above,  is  the  retropubic  or  prevesical  space,  con- 
taining lax  connective  tissue  (Fig.  95).  The  loose- 
ness of  this  connective  tissue  permits  the  bladder 
readily  to  ascend  as  it  fills.  In  injuries  to  the 
pelvis  and  to  the  front  of  the  bladder  a  diffuse 
inflammation  may  be  set  up  in  this  tissue  and 
assume  serious  proportions.  I  have^  reported  a 
case  where  an  extensive  suppuration  in  this  area 
followed  upon  aspiration  of  the  bladder  above 
the  pubes,  and  led  to  death.  Like  suppuration 
has  followed  suprapubic  lithotomy.  Extension  of 
the  abscess  into  the  perineum  is  limited  by  the 
fascial  reflections  formed  by  the  pubo-prostatic 
and  lateral  vesical  ligaments. 

The  bladder,  although  fairly  fixed,  has  been 
found  in  inguinal,  femoral,  and  vaginal  hernise. 
In  the  erect  position  its  neck  (in  the  male)  lies 
on  a  horizontal  line  drawn  from  before  backwards 
through  a  point  a  little  below  the  middle  of  the 
symphysis,  and  is  placed  about  l\  inches  (3  cm.) 
behind  that  articulation   (Tillaux). 

Relations  of  the  bladder  to  the  peritoneum. — The 
anterior  surface  is  entirely  devoid  of  peritoneum, 
while  the  superior  surface  is  entirely  covered  by  that 
membrane.  At  the  sides  there  is  no  peritoneum 
in  front  of,  or  below,  the  obliterated  hypogastric 
arteries.  On  the  posterior  aspect  of  the  bladder 
the  serous  membrane  extends  down  as  far  as  a 
transverse  line  uniting  the  upper  parts  of  the 
two  seminal  vesicles,  so  that  the  upper  ends  of 
the   vesicles   are   covered   by   peritoneum.       This 


468         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

recto-vesical  pouch  of  peritoneum  in  the  adult  ex- 
tends to  within  about  3  inches  of  the  anus,  and 
does  not  reach  below  a  line  1  inch  above  the  base 
of  the  prostate.  Harrison  Cripps  gives  the  dis- 
tance of  the  pouch  from  the  anus  as  2j  inches 
when  the  bladder  and  rectum  are  both  empty, 
and  as  3i  inches  when  those  viscera  are  distended. 
(See  Bladder  in  the  Child,  p.  472.) 

Puncture  of  the  bladder  per  rectum. — The 
base  of  the  bladder  is  applied  to  the  lower  part 
of  the  rectum,  but  they  are  separated  by  a 
thin  fibrous  septum — the  recto-vesical.  The  area 
in  contact  with .  the  rectum  is  triangular  in 
shape,  the  apex  being  formed  ^  by  the  ^  prostate, 
the  sides  by  the  diverging  seminal  vesicles,  and 
the  base  by  the  recto-vesical  fold  of  peritoneum. 
This  triangle  is  equilateral,  and  in  the  dissected 
specimen  measures  about  lj  inches  on  all  sides. 
It  corresponds  to  the  trigone  on  the  inner  surface 
of  the  viscus.  It  is  through  this  triangle,  and 
as  near  as  possible  to  the  prostate,  that  the  blad- 
der is  tapped  when  the  operation  is  performed 
per  rectum.  The  recto-vesical  fold  of  peritoneum 
is  raised,  and  is  carried  still  farther  from  the 
anus  when   the  organ   is   distended. 

Rupture  of  bladder.— The  bladder  may  be 
ruptured  by  violence  applied  to  the  anterior 
abdominal  wall  apart  from  pelvic  fracture  or 
external  evidence  of  injury.  Such  a  rupture  can, 
however,  hardly  happen  to  the  empty  bladder; 
it  must  be  full  or  distended  at  the  time  of  the  acci- 
dent. ^  It  is  very  rare  for  the  rupture  to  be  on  the 
anterior  surface  only.  As  a  rule,  the  tear  in- 
volves the  superior  or  abdominal  surface,  and 
implicates  the  peritoneum.  The  injury,  therefore, 
is  very  fatal  (5  recoveries  out  of  78  cases). 
In  some  cases  of  vesical  rupture  the  surgeon 
has  opened  the  abdomen  and  has  stitched  up 
the  rent  in  the  viscus  with  perfect  success.  The 
bladder  may  be  torn  by  fragments  of  bone  in 
fractures  of  the  pelvis,  or  by  violence  applied 
through  the  rectum  or  vagina.     A  case,   for  ex- 


XX]         RUPTURE  OF  BLADDER         469 

ample,  is  reported  (Holmes's  "  System  of  Sur- 
gery ;;)  of  a  man  who  fell  upon  a  pointed  stake 
fixed  in  the  earth.  The  stake  passed  through  the 
anus,  pierced  the  rectum,  and  entered  the  bladder 
near  the  prostate.  The  patient  recovered,  the 
wound  having  been  made  in  the  triangular  area 
on  the  fundus  of  the  bladder  alluded  to  above, 
and  therefore  outside  the  peritoneum.  The  viscus 
may  be  ruptured  by  an  accumulation  of  urine,  as 
seen  in  cases  of  congenital  closure  of  the  urethra 
in  some  infants.  In  the  museum  of  the  Royal 
College  of  Surgeons  is  a  preparation  of  "  the 
bladder  of  a  woman  which  burst  near  the  entrance 
of  the  ureter  in  consequence  of  neglected  reten- 
tion of  urine. "  In  neglected  cases  of  stricture  in 
the  male  the  urethra  gives  way  rather  than  the 
bladder,  and  an  extravasation  of  urine  into 
the  perineum  follows.  A  small  puncture  of  the 
bladder,  as,  for  example,  that  made  by  a  fine 
trocar,  is  at  once  closed  by  the  muscular  con- 
traction of  its  wall. 

The  mucous  membrane  of  the  bladder  is 
very  lax,  to  allow  of  its  accommodating  itself  to 
the  varying  changes  in  the  size  of  the  viscus. 
Over  the  trigone,  however,  it  is  closely  adherent, 
and  were  it  not  so  the  loose  mucous  membrane 
would  be  constantly  so  prolapsed  into  the  urethral 
orifice  during  micturition  as  to  block  up  the  neck 
of  the  bladder.  When  examined  by  the  cystoscope, 
the  mucous  membrane  is  seen  to  be  red  and  con- 
gested when  the  bladder  is  empty,  pale  and 
anaemic  when  the  bladder  is  full  (Newman).  The 
trigone  is  bounded  by  three  orifices,  for  the  ure- 
thra and  the  two  ureters,  and  forms  an  equilateral 
triangle,  measuring  about  lj  inches  on  all  sides. 
It  is  here  that  the  effects  of  cystitis  are  most  evi- 
dent, and  the  unyielding  character  of  the  mucous 
membrane  over  the  trigone  serves  in  part  to  ex- 
plain the  severe  symptoms  that  follow  acute  in- 
flammation of  that  structure.  Since  the  orifice 
of  the  urethra  forms  the  lowest  part  of  the  bladder 
in  the  erect  posture,  it  follows  that  calculi  gravi- 


470         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

tate  towards  the  trigone^  and  are  very  apt  to 
irritate  that  part  of  the  interior.  The  same  re- 
mark applies  to  foreign  bodies  in  the  viscus.  The 
mucous  membrane  about  the  trigone  and  neck  is 
very  sensitive,  whereas  the  interior  of  the  re- 
mainder of  the  bladder  appears  to  be  singularly 
defective  in  common  sensation.  This  can  be  well 
noted  in  using  sounds  and  catheters. 

The  sensory  nerves  for  the  bladder  are  de- 
rived mainly  from  two  parts  of  the  spinal  cord, 
namely,  the  twelfth  dorsal  and  first  lumbar  seg- 
ments, and  the  second,  third,  and  fourth  sacral 
segments.  t  From  the  first  source  (through  the 
hypogastric  plexus)  come  the  sensory  nerves  to 
the  upper  part  of  the  bladder  and  the  motor 
nerves  which  stimulate  the  internal  sphincter  and 
inhibit  the  expelling  musculature;  from  the 
second  source  (through  the  nervi  erigentes)  the 
motor  fibres  which  stimulate  the  expelling^  mus- 
culature and  inhibit  the  sphincter.  The  trigone, 
having  the  same  nerve  supply  as  the  j)enis  and 
scrotum,  gives  rise,  when  injured,  to  pains  which 
are  referred  along  the  perineal   nerves. 

In  the  muscular  coat  of  the  bladder  the^  fibres 
are  collected  in  bundles^  which  interlace  in  all 
directions.  When  the  viscus  becomes  hypertro- 
phied  these  bundles  are  rendered  very  distinct, 
and  produce  the  appearance  known  as  "fascicu- 
lated bladder. "  This  simply  means  that  the 
muscle  of  the  bladder,  having  been  unduly  exer- 
cised to  overcome  some  obstruction  to  the  escape 
of  urine,  increases  in  size,  as  do  other  much- 
exercised  muscles,  and  that  increase  #  serves  to 
demonstrate  the  arrangement  of  the  individual 
bundles.  From  distension  the  mucous  membrane 
becomes  bulged  out  between  the  unyielding  muscle 
bundles,  so  that  sacculi  are  formed,  and  the  ap- 
pearance known  as  "  sacculated  bladder  "  is  pro- 
duced. In  some  cases  the  parietes  yield,  especially 
at  one  part,  and  one  large  saccule  is  produced. 
In  this  way  a  sacculus  may  be  formed  which  in 
time  may  become  almost  as  large  as  the  bladder 


XX]  THE    URETER  471 

itself,  and  give  rise  to  the  erroneous  description 
of  "  double  bladder/'  etc. 

The  ureters  run  for  f  of  an  inch  in  the  mus- 
cular wall  of  the  viscus,  and  their  oblique  course, 
together  with  the  action  of  the  neighbouring 
vesical  musculature,  prevents  the  regurgitation  of 
urine  from  the  bladder.  No  circular  muscular 
fibres  surround  the  termination  of  the  ureter ; 
there  is  nothing  of  the  nature  of  a  sphincter  to 
safeguard  the  orifice  (T.  B.  C.  Benians).  On 
cystoscopic  examination  it  is  seen  that  once  or 
twice  a  minute  each  ureter  contracts  and  expels 
a  spurt  of  urine  into  the  bladder;  between  these 
spurts  the  ureteric  orifices  are  closed  by  the  intra- 
vesical pressure.  If  the  ureter  becomes  shortened, 
as  is  the  case  if  it  is  the  seat  of  a  tubercular 
ulceration,  the  vesical  orifice  of  the  ureter  is 
drawn  outwards  (Fenwick).  The  mucous  mem- 
brane is  laxly  attached  and  may  be  prolapsed 
within  the  bladder  as  a  pedunculated  body.  In 
cases  of  retention  the  ureters  become  distended ; 
but  this  is  due  rather  to  accumulation  of  urine 
within  them  than  to  its  reflux  from  the  bladder. 
In  cases  of  great  distension  of  the  bladder  the 
neck  of  the  viscus  is  opened  up  by  the  pressure 
from  within,  and  the  patient  exhibits  the  feature 
of  overflow  of  urine.  A  band  of  muscle  passes 
from  the  sheath  of  the  ureter  towards  the  in- 
ternal urinary  meatus  along  each  side  of  ^  the 
trigone  (Bell's  muscle),  while  another  (Mercier's 
bar)  unites  the  orifices  across  the  base.  These 
bands  maintain  the  ureteral  orifices  in  position 
when  the  bladder  is  full,  and  safeguard  their 
valvular  mechanism  (Wright  and  Benians). 

The  female  bladder  is  less  capacious  than 
that  of  the  male.  Its  neck  is  situated  a  trifle 
nearer  to  the  symphysis  than  it  is  in  the  male, 
and  lies  in  a  horizontal  line  continued  back  from 
the  lower  border  of  the  symphysis.  There  being 
no  prostate,  the  neck  of  the  bladder  is  very  dis- 
tensible, and  this  fact,  taken  in  connexion  with 
the    shortness    and    dilatability    of    the    urethra, 


472         THE    ABDOMEN    AND    THE    PELVIS 


[Chap. 


allows  of  most  stones  being  extracted  by  forceps 
without  cutting.  By  simple  dilatation,  stones  of 
a  diameter  of  f  of  an  inch  have  been  removed. 
Through  the  dilated  urethra  the  orifices  of  the 
ureters  can  be  seen  and  examined.  The  intimate 
relation  of  the  bladder  to  the  vagina  allows  it  to 
be  examined  well  from  the  latter  passage,  and 
the  comparative  thinness  of  the  dividing  wall 
serves  to  explain  the  frequency  of  vesico-vaginal 
nstulse.^  Strange  foreign  bodies  have  been  intro- 
duced into  the  female  bladder,  such  as  hair-pins, 
crochet-hooks,  sealing-wax,  penholders,  and  the  like. 

The  orifice  of  the  ureter  is  3  cm.  from  the  cervix 
uteri,  and  4  cm.  from  the  vesical  opening  of  the 
urethra.  Its  close  relation  to  the  cervix  renders 
it  liable  to  injury  in  supravaginal  amputation  of 
that  part,  and  in  certain  operations  on  the 
uterus. 

The  bladder  in  the  child  is  egg-shaped,  and 
its  vertical  axis  is  relatively  much  greater  than 
it  is  in  the  adult.  The  larger  end  of  the  egg- 
shaped  cavity  is  directed  downwards  and  back- 
wards. The  fundus  is  developed  and  the  pelvic 
position  assumed  about  the  fourth  year  (Birming- 
ham). The  viscus  is  situated  mainly  in  the  abdo- 
men, the  pelvis  being  small  and  very  shallow.  At 
birth  the  orifice  of  the  urethra  is  on  a  level  with 
the  upper  edge  of  the  symphysis.  Although  the 
bladder  projects  so  freely  into  the  abdomen,  its 
anterior  wall  is  still  entirely  uncovered  by  peri- 
toneum. On  the  posterior  wall  the  serous  mem- 
brane extends  lower  down  than  in  the  adult, 
reaching  the  level  of  the  urethral  orifice  at  the 
time  of  birth,  and  the  level  of  the  prostate  in 
young  male  children.  The  prostate  is  exceedingly 
small  in  children.  Thompson  states  that  at  the 
age  of  7  years  it  only  weighs  30  grains,  whereas 
in  subjects  between  18  and  20  weighs  250  grains. 
The  bladder  wall  in  the  child  is  so  thin  that  in 
sounding  for  stone  it  is  said  that  a  "click" 
may  be  elicited  by  striking  the  pelvis  through 
the  parietes  of  the  viscus. 


XX] 


PEOSTATE    GLAND 


473 


The  prostate.  — The  prostate  is  situated  about 
|  of  an  inch  below  the  symphysis  pubis,  and  rests 
upon  the  rectum  above  the  anal  canal  (Fig.  94). 
It  is,  therefore,  placed  within  1^  to  2  inches  from 
the  anus,  and  can  be  readily  examined  from  the 
bowel.  The  prostate  is  made  up  of  two  lateral 
lobes  which  fuse  together  in  front  of  the  urethra 
by  a  pubic  commissure  (Fig.   95)  and  behind  by 


Fig.    95. — 1,    Median    section    of    the    normal    prostate ; 
2,  similar  section  of  enlarged  prostate. 

A,  A,  Sphincter  vesicae  ;  B,  median  commissure ;  C,  common  ej  a  di- 
latory duct ;  D,  rectal  commissure  ;  E,  E,  constrictor  urethrse ; 
F,  recto-urethral  muscle  ;  G,  Cowper's  gland  ;  H,  ejaculator  urinae  ; 
I,  internal  sphincter  of  anus  ;  J,  external  sphincter  of  anus  ; 
K,  symphysis  pubis  ;  L,  retropubic  space  ;  M,  pubo-prostatic  liga- 
ments and  sheath  of  prostate  ;  N,  dorsal  vein  of  penis  ;  o,  pubic 
commissure  ;  P,  corpus  cavernosum  ;  Q,  urethra :  R,  bulb. 

two  commissures,  one  above  the  common  ejacula- 
tory  ducts — the  median  commissure — and  one  be- 
low these  ducts — the  rectal  commissure  {see  Fig. 
95,  b,  d).  The  part  here  named  median  commis- 
sure was  formerly  known  as  the  median  lobe — a 
name  which  is  apt  to  mislead,  for  it  is  not  a 
separate  lobe,  but,  as  already  explained,  merely 
|  a  fusion  of  the  two  lateral  lobes.  Each  gland 
is  made  up  of  numerous  branching  tubular  glands 


474         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

which  are  embedded  in  and  surrounded  by  non- 
striated  muscle  and  fibrous  tissue.  The  glands 
end  in  the  urethra — chiefly  in  the  prostatic 
sinuses — but  the  use  of  their  secretion  is  un- 
known. 

The  secretion  from  the  gland  is  discharged 
through  the  long  and  very  narrow  ducts  of  glands 
which  are  diffusely  arranged  as  two  lateral  masses 
or  lobes.  In  certain  forms  of  prostatic  irrita- 
tion, little  white  opaque  threads,  very  much  like 
short  pieces  of  cotton,  are  found  in  the  urine, 
and  are  actual  casts  of  the  prostatic  ducts. 

Capsule  of  the  prostate. — Owing  to  the  suc- 
cess which  has  attended  enucleation  as  a  means 
of  treatment  for  enlarged  prostate,  much  dis- 
cussion has  recently  taken  place  concerning  its 
ensheathing  structures.  The  term  capsule  has 
been  proposed  for  the  superficial  fibro-muscular 
stratum  of  the  gland,  while  the  term  sheath 
has  been  applied  to  the  enveloping  fibrous  struc- 
ture derived  from  the  pelvic  fascia.  In  enu- 
cleating the  gland  everything  within  the  sheath 
is  removed.  At  only  one  part  is  the  sheath  in- 
timately adherent  to  the  capsule,  and  that  is 
along  the  anterior  or  pubic  surface;  elsewhere 
it  is  free  from  it.  Since  the  base  of  the  prostate  is 
applied  to  the  bladder  and  uncovered  by  the 
sheath,  while  elsewhere  it  is  enclosed,  it  follows 
that  the  sheath  is  most  easily  entered  and  the 
gland  enucleated  from  the  bladder.  The  sheath 
determines  the  course  of  a  prostatic  abscess.  p  The 
apex  of  the  prostate  rests  on  the  constrictor 
urethrae ;  its  sides  are  applied  to  the  pubo-rectal 
fibres  of  the  levator  ani ;  hence  the  capsule  of 
the  prostate  fuses  with  the  adjacent  sheaths  of 
these  two  muscles.  The  prostatic  plexus  of  veins, 
which  receives  the  vesical  veins,  tributaries  and 
communications  of  the  dorsal  vein  of  the  penis, 
internal  pudic  and  obturator  veins,  lies  in  the 
fibrous  tissue  between  the  prostate  and  levator 
ani.  The  tissue  to  the  outer  side  of  the  veins 
is  counted  capsule ;  that  to  the  inner,  sheath.    The 


XX]  PROSTATIC    HYPERTROPHY  475 

capsule  of  the  prostate  behind  is  formed  by  the 
recto-vesical  septum. 

The  prostatic  abscess  usually  bursts  into 
the  urethra,  that  being  the  direction  in  which 
least  resistance  is  encountered.  If  it  does  not 
enter  the  urethra,  it  will  probably  open  into  the 
rectum,  there  being  only  one  layer  of  the  pelvic 
fascia,  and  that  layer  not  a  thick  one,  between 
the  two  organs.  This  encasement  of  the  gland 
in  an  unyielding  membrane  will  serve,  in  part, 
to  explain  the  severe  pain  felt  in  acute  prostatic 
abscess.  In  acute  prostatitis  pains  are  referred 
over  the  tip  of  the  last  rib  (10th  dorsal  nerve), 
over  the  posterior  iliac  spine  (11th  dorsal  nerve), 
or  even  to  the  soles  of  the  feet  (3rd  sacral 
nerve).  The  prostate  derives  its  nerve  supply  from 
the  lower  three  dorsal  and  upper  three  sacral 
segments;  hence  the  widely  distributed  character 
of   the   referred   pains    (Head). 

Hypertrophy  of  the  prostate.  —  The  average 
measurements  of  the  normal  prostate  are  1\  inches 
across  at  its  widest  part,  and  1\  inches  from 
before  backwards,  or  from  apex  to  base.  After 
the  age  of  53  the  organ  is  very  apt  to  become 
hypertrophied ;  and,  according  to  Sir  Henry 
Thompson,  this  hypertrophy  may  be  considered 
to  exist  when  the  gland  measures  2  inches  from 
side  to  side,  or  when  it  weighs  1  ounce  or  more. 
The  usual  weight  of  the  prostate  is  6  drachms.  If 
the  enlargement  mainly  affect  the  lateral  parts, 
it  will  be  understood  that  the  hypertrophy  may 
attain  considerable  dimensions  without  retention 
of  urine  being  produced.  On  the  other  hand,  a 
comparatively  trifling  enlargement  of  the  median 
commissure  may  almost  entirely  block  the  orifice 
of  the  urethra.  As  this  part  enlarges  it  pushes 
its  way  into  the  bladder  through  the  urethral 
orifice,  dilating  and  destroying  the  sphincter 
vesicae  and  forming  a  mechanical  obstruction  to 
the  free  passage  of  urine  (Fig.  95,  2).  If  the 
affection  be  general,  the  prostatic  urethra  is 
lengthened,   and  if  one  lateral  lobe  be  more  en- 


476         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

larged  than  the  other,  the  canal  deviates  to  one 
side.  When  the  enlargement  particularly  affects 
the  median  commissure,  the  prostatic  urethra, 
which  is  normally  almost  straight,  becomes  con- 
siderably curved,  the  curve  being  sometimes  very 
abrupt.  It  is  important  to  note  that  enlarge- 
ment of  the  median  commissure  alone  can  hardly 
be  made  out  by  rectal  examination.  The  project- 
ing middle  commissure,  when  viewed  from  the  in- 
terior of  the  bladder,  may  appear  as  a  distinct, 
well-rounded,   pedunculated  or  sessile  growth. 

In  the  operation  of  prostatectomy  this  pro- 
jecting and  most  troublesome  mass  is  removed 
through  a  suprapubic  incision.  Everything 
within  the  sheath  of  the  prostate — gland,  urethra, 
common  ejaculatory  ducts — is  enucleated  by  the 
surgeon's  finger  through  the  base  of  the  bladder ; 
the  sheath  then  encloses  a  space  which  at  first  is 
filled  with  blood  and  urine,  but  afterwards  con- 
tracts to  form  a  new  urethra.  The  prostate  is  a 
sexual  organ,  and  its  size  and  development  de- 
pend on  the  presence  and  activity  of  the  testes. 
Castration  prevents  its  development  or  causes 
atrophy  if  already  developed.  Removal  of  one 
testicle  causes  a  partial  atrophy,  but  section  of 
the  vasa  deferentia  has  usually  no  effect  (C. 
Wallace).  The  lymphatics  of  the  prostate,  which 
are  numerous,  pass  to  a  group  of  glands  on 
the  wall  of  the  pelvis,  between  the  external  and 
internal  iliac  arteries. 

The  male  urethra  is  about  8£  inches  in 
length  (21  cm.),  \\  inches  being  devoted  to  the 
prostatic  urethra,  f  of  an  inch  to  the  mem- 
branous, and  6j  inches  to  the  penile  or  spongy 
portion.  Between  the  ages  of  4  and  6  years 
its  length  is  8  to  9  cm.,  and  between  10  and 
13  years  10  to  11  cm.  The  canal  may  be  divided 
into  a  fixed  and  a  movable  part.  The  fixed  part 
extends  from  the  neck  of  the  bladder  to  the 
posterior  extremity  of  the  penile  urethra  at  the 
point  of  attachment  of  the  suspensory  ligament. 
This   fixed   part   describes   an   even   curve,    fairly 


XX]  MALE    URETHRA  477 

represented  by  the  line  of  a  "  short  curve  "  metal 
catheter.  The  two  ends  of  the  curve  lie  about  in 
the  same  line,  viz.  one  drawn  across  the  lower 
end  of  the  symphysis,  and  at  right  angles  to  the 
vertical  axis  of  that  articulation.  The  curve  is 
formed  around  this  line,  its  centre  summit  corre- 
sponding to  a  prolongation  of  the  vertical  axis  of 
the  symphysis,  and  to  about  the  centre  of  the  mem- 
branous urethra.  This  part  of  the  tube  lies  about 
1  inch  below  the  pubic  arch.  The  movable  portion 
of  the  urethra  forms,  when  the  penis  is  dependent, 
a  second  curve  in  the  opposite  direction,  so  that 
the  whole  canal  follows  somewhat  the  outline  of 
the  letter  S. 

The  prostatic  portion  of  the  urethra  is  nearly 
vertical.  <  It  is  surrounded  by  circular  muscular 
fibres  which  may  give  rise  to  a  spasmodic  stricture 
(.Fig.  95).  The  sinus  pocularis  or  uterus  mascu- 
linus,  in  the  floor  of  this  part  of  the  urethra, 
represents  the  united  ends  of  the  rudimentary 
Miillerian  ducts. 

The  penile  or  spongy  portion  of  the  urethra 
is  surrounded  by  the  erectile  tissue  of  the  corpus 
spongiosum  urethras,  which  is  thickest  on  the 
under  side  of  the  canal.  A  very  thin  layer  of 
erectile  tissue  surrounds  the  membranous  urethra 
lying  beneath  the  fibres  of  the  compressor 
urethrae. 

In  introducing  a  catheter  it  must  be  noted 
that  while  the  instrument  passes  along  the  mov- 
able urethra,  the  canal  accommodates  itself  to  the 
catheter,  but  while  traversing  the  fixed  segment 
the  instrument  must  accommodate  itself  to  the 
unyielding  canal.  In  introducing  a  catheter  in 
the  recumbent  posture  the  penis  is  held  vertically 
upwards,  and  in  this  way  the  curve  formed  by 
the  movable  urethra  is  obliterated.  The  instru- 
ment is  best  kept  close  to  the  surface  of  the  groin, 
and  over  and  parallel  to  Poupart's  ligament. 
When  the  fixed  urethra  is  reached,  the  handle  of 
the  catheter  is  brought  to  the  middle  line,  and 
then,  being  kept  strictly  in  the  median  plane  of 


478         THE    ABDOMEN    AND    THE    PELVIS    [Chap 

the  body,  is  depressed  between  the  legs,  so  that  the 
front  of  the  instrument  may  follow  the  natural 
curve  of  the  canal.  The  greatest  difficulty  in  the 
introduction  is  generally  experienced  at  the  point 
where  the  movable  and  fixed  parts  of  the  urethra 
meet;  or,  rather,  in  practice,  at  a  spot  a  little 
behind  this  point,  viz.  at  the  anterior  layer  of 
the  triangular  ligament  (Fig.  95).  At  this  spot 
the  tube  abruptly  becomes  not  only  very  fixed, 
but  also  very  narrow,  and  a  part  of  it  is  reached 
where  muscular  tissue  is  very  abundant,  and 
where  resistance  from  muscular  spasm  is  there- 
fore likely  to  be  most  marked. 

It  thus  happens  that  when  a  false  passage  has 
been  made  by  a  catheter  in  a  case  where  no 
stricture  exists  to  offer  a  definite  obstruction,  the 
instrument  is  usually  found  to  have  left  the  canal 
just  in  front  of  the  triangular  ligament. 

Some  other  points  in  connexion  with  cathe- 
terization will  be  noted  subsequently. 

The  urethral  canal  must  not  be  regarded 
as  forming  an  open  tube  like  a  gas-pipe.  Except 
when  urine  or  an  instrument  is  passing  along  it, 
the  tube  appears  on  section  as  a  transverse  slit, 
the  superior  and  inferior  walls  being  in  contact. 
This  fact  should  be  remembered  in  amputation  of 
the  penis  by  the  ecraseur.  In  the  fossa  navicu- 
lars the  tube  appears  as  a  vertical  slit. 

The  prostatic  part  of  the  canal  is  the  widest 
and  most  dilatable  portion  of  the  whole  urethra. 
It  is  widest  at  its  centre,  having  here  a  diameter 
of  nearly  \  an  inch;  at  the  bladder  end  its  dia- 
meter is  about  \  of  an  inch,  while  at  the  anterior 
extremity  of  this  part  of  the  urethra  the  measure- 
ment is  a  little  less  than  J  of  an  inch.  When 
small  catheters  are  being  introduced  their  points 
may  lodge  in  the  orifice  of  the  utricle,  unless  the 
tip  of  the  instrument  be  kept  well  along  the  roof 
of  the  canal.  The  ejaculatory^  ducts  open  into  the 
prostatic  urethra,  and  thus  it  happens  that  in- 
flammation of  this  part  of  the  canal  may  spread 
back  along  those  ducts  to  the  seminal  vesicles,  and 


XXJ  THE    UEETHEA  479 

from  thence  along  the  vas  deferens  to  the  epi- 
didymis (Fig.  95).  It  is  by  spreading  along  these 
parts  that  inflammation  of  the  testicle  is  set  up 
in  gonorrhoea  involving  the  prostatic  urethra, 
and  it  will  be  understood  that  a  like  inflam- 
mation may  follow  lateral  lithotomy,  impacted 
stone  in  the  prostatic  urethra,  prostatic  abscess, 
and  the  like.  Stricture  never  occurs  in  this 
part. 

The  membranous  urethra  is,  with  the  exception 
of  the  meatus,  the  narrowest  part  of  the  entire 
tube.  Its  diameter  is  about  \  of  an  inch.  It  is 
fixed  between  the  two  layers  of  the  triangular 
ligament,  and  is  the  most  muscular  part  of  the 
canal.  It  is  at  this  spot,  therefore,  that  what  is 
known  as  "spasmodic  stricture "  usually  occurs. 
In  any  case,  the  contraction  of  the  constrictor 
urethrae  often  offers  an  appreciable  amount  of 
resistance  to  the  passage  of  a  catheter  or  sound 
(Fig.  95). 

The  penile  urethra  is  dilated  at  either  end, 
viz.  at  the  parts  occupying  the  bulb  and  the  glans 
penis  respectively.  The  diameter  of  the  bulbous 
urethra  is  midway  between  that  of  the  prostatic 
and  membranous  segments  of  the  canal,  while  that 
of  the  greater  part  of  the  penile  urethra  is  mid- 
way between  that  of  the  bulbous  and  membran- 
ous portions.  It  is  in  the  bulbous  urethra  that 
organic  stricture  is  the  most  commonly  met  with. 
The  meatus  measures  from  \  to  \  of  an  inch, 
and  therefore  if  a  catheter  will  pass  the  meatus 
it  will  pass  along  any  part  of  the  normal  canal. 
Its  aperture  is  very  resisting,  and  has  often  to 
be  incised  to  allow  the  larger  instruments  to 
pass. 

The  narrowest  parts  of  the  urethra,  therefore, 
are  (1)  at  the  meatus,  and  (2)  in  the  membranous 
segment,  especially  at  its  anterior  end.  It  is 
at  these  points  that  calculi  passed  from  the  blad- 
der are  most  apt  to  lodge.  The  widest  portions 
of  the  canal,  on  the  other  hand,  are  at  (1)  the 
fossa   navicularis,    (2)    the   bulbous   part   of   the 


480         THE    ABDOMEN    AND    THE    PELVIS    [Chap, 


urethra,    and    (3)    the    centre    of    the    prostatic 
portion. 

The  mucous  membrane  of  the  urethra  pre- 
sents, in  addition  to  many  mucous  glands,  several 
lacunae,  the  orifices  of  which  for  the  most  part 
open  towards  the  meatus.  These  lacunae  are 
most  numerous  in  the  bulbous  urethra,  and  occupy 
the  floor  rather  than  the  roof  of  the  canal.  In 
passing  small  catheters,  therefore,  the  point  of 
the  instrument  should  be  kept  along  the  upper 
surface  of  the  tube,  so  that  it  may  not  become 
engaged  in  any  of  these  spaces.  The  largest 
lacuna,  the  lacuna  magna,  is  situate  in  the  roof 
of  the  fossa  navicularis,  and  may  readily  engage 
the  point  of  a  small  instrument. 

The  urethra  may  be  ruptured  by  the  patient 
falling  astride  of  some  hard  substance.  In  such  an 
injury  it  is  crushed  between  the  hard  substance 
and  the  pubic  arch.  The  part  of  the  canal,  there- 
fore, that  is  most  often  damaged  is  the  mem- 
branous segment,  and  the  posterior  part  of  the 
penile  division.  The  more  the  body  is  bent  for- 
wards at  the  time  the  perineum  is  struck,  the 
greater  is  the  length  of  penile  urethra  that  may  be 
crushed  against  the  pubes. 

The  female  urethra  is  about  \\  inches  in 
length,  and  has  a  diameter  of  from  i  to  J  of  an 
inch.  It  is  capable,  however,  of  great  distension. 
In  the  erect  position  the  canal  is  nearly  vertical, 
and  in  the  recumbent  posture  almost  horizontal. 
The  penis. — The  skin  covering  the  bulk  of  the 
organ  is  thin  and  fine,  and  the  subcutaneous  tissue 
is  scanty  and  lax.  It  follows,  from  the  looseness 
of  this  tissue,  that  the  skin  is  very  distensible 
and  movable^  The  latter  fact  should  be  borne 
in  mind  in  circumcision,  for  in  performing  that 
operation  the  skin  of  the  penis  can  be  so  readily 
drawn  forwards  over  and  beyond  the  glans,  that 
if  it  is  excised  as  far  back  as  possible  the  greater 
part  of  the  organ  may  be  left  bare.  This  applies, 
of  course,  mainly  to  children.  The  laxity  of 
the   submucous   tissue   permits   the   organ   to   be- 


: 


XX] 


THE    PENIS 


481 


come  enormously  swollen  when  cedematous,  or 
when  extravasated  urine  finds  its  way  into  the 
part.  Over  the  glans  penis  the  mucous  mem- 
brane is  so  adherent  that  there  is  practically  no 
subcutaneous  tissue.  It  happens,  therefore,  that 
when  Hunterian  chancres  appear  on  this  part 
they  can  never  be  associated  with  other  than  the 
most  trifling  induration,  there  being  no  tissue  in 
which  the  thickening  can  develop.  At  the  corona, 
on  the  other  hand,  the  submucous  tissue  is  lax 
and  plentiful,  so  that  the  induration  can  readily 
form,  and  it  is  about  this  spot,  therefore,  that  the 
syphilitic  sore  often  attains  its  most  characteristic 


Prepuce 

Corp.Cavermosum 
Clams. 

LACUNA  AlAQ/iA-    (f& 
P05SA  /1AVICULARI5 
PERMANENT    MCATl 

Primitive  AIbatus 


Fig.  96. — Section  of  a  penis,  showing  a  common  form  of 
hypospadias. 

The  cross  marks  the  point  where  the  tissue  breaks  down  between 
the  cloacal  urethra  and  meatal  ingrowth. 

development.  The  vascularity  of  the  penis,  and 
the  rapid  engorgement  that  ensues  when  the  re- 
turn of  its  venous  blood  is  impeded,  serve  to  ex- 
plain the  ready  and  extensive  swelling  of  the 
organ  that  follows  when  any  constricting  band  is 
placed  about  it.  This  should  be  borne  in  mind  in 
tying  in  a  catheter  by  securing  it  by  tapes  around 
the  penis.  The  blood  spaces  in  the  corpus  spongi- 
osum may  be  rendered  indistensible  from  gonor- 
rhceal  inflammation  while  those  of  the  corpora 
cavernosa  remain  free.  The  corpus  spongiosum 
then  acts  like  the  string  of  a  bow  during  the  erec- 
tion of  the  penis.  Through  the  superficial  lym- 
phatics disease  may  spread  from  the  skin  and 
meatal  region  of  the  penis  to  the  inner  of  the 
Q 


482         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

inguinal  glands.  Deeper  vessels  pass  with  the 
prostatic  veins  to  the  internal  iliac  group  of 
glands  on  the  lateral  wall  of  the  pelvis.  Some 
vessels  pass  directly  to  the  external  iliac  glands 
through  the  crural  ring.  The  penis  is  frequently 
the  seat  of  arrests  of  development,  presenting  a 
variety  of  appearances.  Among  them  may  be  men- 
tioned hypospadias,  where  the  inferior  wall  of  the 
urethra  and  corresponding  part  of  the  corpus 
spongiosum  are  wanting,  and  epispadias,  where 
the  superior  wall  of  the  canal  and  corresponding 
parts  of  the  corpora  cavernosa  are  more  or  less 
entirely  deficient.  In  the  condition  of  hypo- 
spadias two  meati  are  present — one  situated  on 
the  glans  opening  into  a  cul-de-sac  which  repre- 
sents the  fossa^  navicularis,  and  another  just 
behind  leading  into  the  urethra  (Fig.  96).  Here 
is  seen  the  double  origin  of  the  male  urethra — the 
part  within  the  glans  is  formed  by  an  ingrowth 
of  epithelium  from  the  surface  of  the  glans,  while 
the  rest  of  the  penile  urethra  is  derived  from  the 
cloaca.  i  At  first  the  cloacal  urethra  opens  by  its 
own  orifice  (primitive  meatus,  Fig.  96),  but  in  the 
course  of  development  the  ingrowth  from  the  glans 
takes  place  to  form  the  permanent  meatus  and 
fossa  navicularis;  when  this  ingrowth  opens  into 
the  cloacal  urethra  the  primitive  meatus  becomes 
closed.  The  frenum  preputii  is  formed  over  it. 
The  condition  thus  represented  is  one  of  ar- 
rested development.  On  the  prepuce  of  such  cases 
sebaceous  glands  are  arranged  in  two  pigmented 
oval  groups — preputial  ocelli  (Shillitoe). 

The  scrotum.— The  skin  of  the  scrotum  is 
thin  and  transparent,  so  that  in  bruising  of  the 
parts  the  discoloration  due  to  the  extravasation  of 
blood  beneath  the  surface  is  readily  and  distinctly 
seen.  It  is  alsovery  elastic,  and  allows  of  great 
distension,  as  is  seen  in  large  scrotal  hernise 
and  testicular  tumours.  The  integument  of  the 
part  is  indeed  #  redundant,  and  the  excision 
of  a  portion  of  it  will  hardly  be  missed.  Even 
in  gangrene  of  the  scrotum,   when  both  testicles 


XX]  THE    SCROTUM  483 

have  been  exposed,  the  parts  have  been  entirely 
restored  without  any  inconvenient  shrinking  or 
contraction.  The  rugce  on  the  surface  of  the  scro- 
tum favour  the  accumulation  of  dirt,  and  the 
irritation  set  up  by  such  accumulation  may  be 
the  exciting  cause  of  the  epitheliomata  that  are 
not  uncommon  in  this  part.  When  the  surface  is 
sweating,  the  rugse  tend  to  favour  a  retention  of 
the  moisture  between  their  folds;  from  this  and 
other  circumstances  it  happens  that  the  scrotum 
is  liable  to  eczema  and  to  those  syphilitic  skin 
disorders  that  are  often  localized  by  irritation. 
The  rugse  are  a  sign  of  health,  since  they  depend 
upon  the  vigorous  contraction  of  the  muscle  fibres 
in  the  dartos  tissue.  In  the  enfeebled,  or  under 
•  the  relaxing  effects  of  heat,  the  scrotum  becomes 
smooth  and  pendulous.  In  a  simple  incised 
wound,  as  in  castration,  the  dartos  is  apt  to  turn 
in  the  edges  of  the  skin  and  cause  some  difficulty 
in  applying  the  sutures.  This  difficulty  may  be 
avoided  by  relaxing  that  tissue  for  a  while  by  the 
application  of  a  warm  sponge  to  the  wound. 

The  subcutaneous  tissue  is  lax  and  very  ex- 
tensive, and  permits  of  considerable  extravasa- 
tions of  blood  forming  beneath  the  surface.  It 
is  unadvisable,  therefore,  to  apply  leeches  to  the 
scrotum  itself,  since  they  may  lead  to  an  unde- 
sirable outpouring  of  blood  beneath  the  skin,  and 
to  the  appearance  of  a  considerable  ecchymosis. 
Leeches  in  testicular  affections  had  better  be  ap- 
plied over  the  region  of  the  cord. 

The  scrotum,  from  its  dependent  position,  and 
from  the  looseness  and  extent  of  its  cellular  tissue, 
is  often  the  first  part  of  the  body  to  become 
cedematous  in  dropsy,  and  is  apt  to  show  that 
cedema  in  a  marked  degree.  The  scrotum  also  is 
the  part  most  frequently  the  seat  of  elephantiasis, 
which  is  due  essentially  to  a  distension  of  the 
lymphatic  vessels  and  spaces  of  the  connective 
tissue.  The  vitalitv  of  the  scrotum  is  not  consider- 
able, and  it  therefore  not  infrequently  sloughs  in 
parts  when  severely  inflamed.      For  this  reason 


484         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

strapping  should  be  applied  with  some  care  over 
the  enlarged  testis,  for  against  the  hard  mass  of 
the  affected  gland  the  integument  of  the  scrotum 
can  be  subjected  to  considerable  pressure  when  the 
strapping  is  tightly  applied.  In  such  a  case  I 
have  seen  the  whole  of  one  side  of  the  scrotum 
slough  from  an  indiscreet  use  of  this  familiar 
method  of  treatment. 

The  testicle  may  be  retained  within  the  ab- 
dominal cavity,  or  may  lodge  for  varying  periods 
of  time,  or  for  life,  in  the  inguinal  canal.  It 
may,  on  the  other  hand,  pass  beyond  the  scrotum 
into  the  perineum,  or  may  miss  the  inguinal  canal 
altogether  and  escape  through  the  femoral  canal 
and  saphenous  opening  on  to  the  thigh.  t  The 
testis  proper  is  entirely  invested  by  the  visceral 
layer  of  the  tunica  vaginalis,  except  over  a  small 
part  of  its  posterior  border  where  the  vessels 
enter.  The  epididymis  is  entirely  covered  by  the 
serous  membrane  at  its  sides,  is  more  or  less  so 
covered  in  front,  but  is  free  or  uncovered  along 
the  greater  part  of  its  posterior  border  (see 
Fig.  74,  p.  356).  ^  It  is  about  the  posterior  border 
of  the  epididymis  that  the  visceral  layer  of  the 
tunica  vaginalis  joins  the  parietal  layer.  The 
posterior  border  of  the  testicle  and  of  the  epi- 
didymis— from  globus  major  to  globus  minor — is 
bound  by  a  reflection  of  serous  membrane — the 
mesentery  of  the  testicle.  Instead  of  binding  the 
whole  of  the  posterior  border,  the  mesentery  may 
be  attached  merely  ^  to  the  lower  pole  of  the 
testicle  and  globus  minor ;  on  such  a  pedunculated 
attachment  the  testicle  is  apt  to  become  stran- 
gulated by  a  twisting  of  its  narrow  mesentery. 
A  narrow^  elongated  mesentery  is  found  only  in 
glands  which  are  late  in  descending  or  have  been 
arrested  in  their  descent ;  torsion  of  the  testicle 
is,  therefore,  only  possible  in  imperfectly  de- 
veloped organs.  The  more  intimate  and  exten- 
sive connexion  of  the  serous  tunic  with  the  testis 
or  gland  proper  serves  in  part  to  explain  the 
greater   frequency  with  which  hydrocele  appears 


XX]  THE    TESTICLE  485 

in  inflammation  of  this  part  of  the  organ,  as 
compared  with  its  occurrence  when  the  epididy- 
mis is  alone  inflamed.  It  is  owing  to  the  reflec- 
tions of  the  tunica  vaginalis  that  in  cases  of 
common  hydrocele  the  testicle  remains  firmly  set 
at  the  lower  and  posterior  part  of  the  swelling, 
and  yet  so  extensively  is  the  organ  surrounded 
by  that  membrane  that  the  position  of  the  gland 
in  the  larger  hydroceles  is  often  difficult  to  deter- 
mine. In  some  cases  the  testicle  occupies  the  front 
of  the  scrotum,  the  epididymis  being  placed  an- 
teriorly, and  the  body  of  the  gland  being  located 
behind  it.  The  vas  deferens  descends  also  along 
the  front  of  the  cord.  In  these  cases  the  testicle 
is  just  in  the  position  it  would  occupy  if  it  had 
been  turned  round  upon  its  vertical  axis.  The 
condition  is  known  as  inversion  of  the  testicle, 
and  should  be  sought  for  in  cases  of  hydrocele, 
as  in  several  instances  the  testis  has  been  pierced 
by  the  trocar  when  tapping  collections  in  cases 
where  the  inversion  existed. 

The  proper  gland  tissue  is  invested  by  a  very 
dense  membrane,  the  tunica  albuginea.  The  epi- 
didymis, on  the  other  hand,  lacks  any  such  firm 
fibrous  investment.  The  unyielding  character  of 
the  tunica  albuginea  serves  in  great  part  to  ex- 
plain the  intense  pain  felt  in  acute  affections 
of  the  testis  proper,  a  degree  of  pain  which  is 
not  reached  when  the  less  tightly  girt  epididymis 
is  alone  involved.  It  will  be  understood  also  that 
in  inflammation  of  the  epididymis  the  part  swells 
rapidly  and  extensively,  while  in  a  like  affection 
of  the  body  of  the  gland  the  swelling  is  compara- 
tively slow  to  appear. 

It  should  be  borne  in  mind  that  the  lymphatics 
of  the  scrotum  go  to  the  inguinal  glands,  those  of 
the  testicleto  the  lumbar;  in  malignant  disease 
of  the  testicle  the  secondary  deposits  are  to  be 
expected  deep  within  the  abdomen  by  the  side  of 
the  aorta.  The  testicle  is  developed  in  front 
of  the  10th  dorsal  vertebra,  and  receives  its  nerve 
supply  from  the  10th  dorsal  segment.     Its  nerves 


486         THE    ABDOMEN    AND    THE    PELVIS    TChap. 

pass  by  the  small  splanchnics,  solar  and  aortic 
plexuses,  to  the  spermatic  artery,  on  which  they 
reach  the  gland.  The  epididymis  receives  its 
nerve  supply  from  the  pelvic  plexus,  along  the 
vas  deferens. 

Spermatic  cord,  — The  structures  in  the 
cord  are  (1)  the  vas  deferens,  (2)  the  cremaster 
muscle,  (3)  the  spermatic  and  (4)  cremasteric 
arteries,  (5)  the  artery  to  the  vas  deferens, 
(6)  the  pampiniform  plexus  of  veins,  (7)  the 
genito-crural  nerve,   (8)  sympathetic  nerve  fibres, 


-S.A 


Fig.  97.— Section  of  the  left  spermatic  cord  of  an  adult,  at 
the  level  of  the  external  abdominal  ring,  viewed  from 
above.     {From  a  specimen  prepared  by  Mr.  W.  G.  Spencer.) 

VD,  vas  deferens  ;  DA,  deferential  artery  ;  DV,  deferential  veins :  SA, 
spermatic  artery  ;  CA,  cremasteric  artery  ;  CM,  cremaster  muscle  ; 
PP,  pampiniform  plexus. 

and  (9)  lymphatics.  The  vas  deferens  lies  along 
the  posterior  aspect  of  the  cord  (Fig.  97),  and 
can  be  detected  by  the  firm,  cord-like  sensation 
which  it  gives  when  pinched  between  the  thumb 
and  finger.  Mr.  Birkett  (Holmes's  "  System ,;) 
gives  three  cases  of  rupture  of  the  vas  deferens 
during  severe  and  sudden  exertion.  The  duct  ap- 
pears to  have  in  each  case  given  way  within  the 
abdomen  at  some  point  between  the  internal  ring 
and  the  spot  where  it  approaches  the  ureter.  Re- 
section of  part  of  the  vas  has  been  practised  to 
bring  about  atrophy  of  enlarged  prostate,  but  has 


XX]  THE    SPERMATIC    CORD  487 

not  proved  successful.  The  size  of  the  cremaster 
muscle  depends  mainly  upon  the  weight  it  has  to 
suspend.  In  atrophy  of  the  testicle  it  almost 
entirely  disappears,  while  in  cases  of  large  slow- 
growing  tumours  of  the  gland  it  attains  consider- 
able proportions.  If  in  children  or  young  adults 
the  skin  over  the  middle  of  the  thigh  just  below 
Poupart's  ligament  be  tickled,  the  testicle  of  the 
same  side  will  usually  be  seen  to  be  suddenly 
drawn  upwards.  The  tickling  concerns  the  crural 
branch  of  the  genito-crural,  while  the  motor  nerve 
of  the  cremaster  is  the  genital  division  of  the  same 
trunk.  The  interval  of  time  that  elapses  between 
the  irritation  of  the  skin  and  the  movement  of 
the  testicle  has  been  appealed  to  as  affording  evi- 
dence of  the  state  of  nerve  health  and  of  the 
readiness  with  which  nerve  impulses  are  con- 
ducted. Of  the  arteries,  the  spermatic  comes  from 
the  aorta  and  lies  in  front  of  the  vas,  the  cre- 
masteric arises  from  the  deep  epigastric  and  lies 
among  the  superficial  layers  of  the  cord  in  its 
outer  segment,  while  the  deferential  artery  from 
the  superior  or  in|erior  vesical  lies  by  the  side  of 
the  vas  (Fig.  97).  The  first-named  vessel  is  the 
size  of  the  posterior  auricular,  and  the  two  latter 
the  size  of  the  supra-orbital.  The  spermatic  artery 
divides  into  a  number  of  branches  as  it  reaches 
the  testicle;  these  branches  pass  to  the  inner  side 
of  the  epididymis,  which  may  be  removed  without 
interfering  with  the  blood  supply  of  the  testicle. 
The  three  arteries  of  the  cord  are  divided  in 
castration,  and  may  all  require  ligature.  It  is 
advisable  to  secure  the  vessels  in  sections,  rather 
than  adopt  the  clumsy  plan  of  involving  the  whole 
cord  in  one  common  ligature.  The  veins  are 
divided  roughly  into  two  sets.  The  anterior  is 
by  far  the  larger  set,  runs  with  the  spermatic 
artery,  and  forms  the  pampiniform  plexus.  The 
posterior  set  is  small  and  surrounds  the  vas, 
running  with  the  deferential  artery.  The  veins 
of  the  spermatic  and  pampiniform  plexus  are 
very  frequently  varicose,  and  then  constitute  the 


488         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

affection  known  as  varicocele.  Many  anatomical 
causes  render  these  veins  liable  to  this  affection 
they  occupy  a  dependent  position,  and  the  main 
vein  is  of  considerable  length,  and  follows  a 
nearly  vertical  course ;  the  vessels  are  very  large 
when  compared  with  the  corresponding  artery, 
and  so  the  vis  a  tergo  must  be  reduced  to  a  mini- 
mum; they  occupy  a  loose  tissue,  and  are  lacking 
in  support  and  in  the  aid  afforded  to  other  veins 
(as  in  the  limbs)  by  muscular  contraction;  they 
are  very  tortuous,  form  many  anastomoses,  and 
have  few  and  imperfect  valves;  they  are  exposed 
to  pressure  in  their  passage  through  the  inguinal 
canal.  The  left  veins  are  more  frequently  affected 
than  the  right.  Mr.  Spencer  has  shown  that  the 
veins  of  -the  left  cord  are  always  much  larger 
than  those  of  the  right.  It  may  also  be  pointed 
out  that  the  left  testicle  hangs  lower  than  the 
right ;  that  the  left  spermatic  vein  enters  the  left 
renal  at  a  right  angle,  while  the  right  spermatic 
vein  passes  obliquely  into  the  vena  cava ;  and  that 
the  left  vein  passes  beneath  the  sigmoid  flexure, 
and  is  thus  exposed  to  pressure  from  the  contents 
of  that  bowel. 

The  female  generative  organs  require 
but  little  notice  in  the  present  volume.  The 
labia  majora  have  the  same  pathological  tenden- 
cies as  has  the  scrotum,  to  which,  indeed,  they 
anatomically  correspond.  They  are  liable  to 
present  large  extravasations  of  blood,  are  greatly 
swollen  when  oedematous,  are  prone  to  slough 
when  acutely  inflamed,  and  are  the  usual  seats  of 
elephantiasis  in  the  female.  A  hernia  may  pre- 
sent in  one  or  other  ■  labium  (pudendal  hernia), 
the  neck  of  the  sac  being  between  the  vagina  and 
the   pubic  ramus. 

"  On  everting  one  of  the  labia  minora  and 
pressing  the  hymen  inwards,  a  small  red  de- 
pression may  generally  be  seen  on  the  vulva, 
somewhat  posteriorly.  It  leads  to  the  orifice  for 
Bartholin's  gland  "  (Doran).  This  gland,  an  oval 
body  about  \  an  inch  in  length,  lies  against  the 


XX]  THE    VAGINA  489 

posterior  part  of  the  vaginal  orifice,  under  the 
superficial  perineal  fascia,  and  covered  by  the 
fibres  of  the  sphincter  vaginae.  It  wastes  after  30. 
It  corresponds  to  the  gland  of  Cowper  in  the 
male  (Fig.  95,  p.  473).  Both  are  apt  to  become 
the  sites  of  chronic  gonorrheal  inflammation. 
Abscess  of  the  gland  and  cystic  dilatation  of  its 
duct  are  not  uncommon. 

The  vagina  is  lodged  between  the  bladder  and 
rectum,  while  the  upper  fourth  of  its  posterior 
surface  is  covered  with  peritoneum,  and  is  there- 
fore in  relation  to  the  abdominal  cavity.  Thus  it 
happens  that  the  bladder,  the  rectum,  or  the 
small  intestines  may  protrude  into  the  vagina  by 
a  yielding  of  some  parts  of  its  walls  and  thus  pro- 
duce a  vaginal  cystocele,  rectocele,  or  enterocele. 

The  anterior  wall  of  the  vagina  measures  a 
little  over  2  inches,  the  posterior  wall  about  3 
inches.  The  long  axis  of  the  canal  forms  an  angle 
of  60°  with  the  horizon,  and  is  therefore  almost 
parallel  to  the  pelvic  brim.  The  loose  areolar 
tissue  at  the  base  of  the  broad  ligament  lies  on 
each  side  of  the  upper  extremity  of  the  vagina. 
The  ureter  terminates  in  the  bladder,  on  the  upper 
part  of  the  vaginal  roof. 

The  abdominal  cavity  may  be  opened  through 
a  wound  of  the  vagina.  In  one  or  two  instances 
of  such  injuries  several  feet  of  intestine  have  pro- 
truded through  the  vulva.  In  one  reported  case 
an  old  woman,  the  subject  of  a  brutal  rape, 
walked  nearly  a  mile  with  several  coils  of  the 
small  bowel  hanging   from  her  genitals. 

From  the  comparative  thinness  of  the  walls 
that  separate  the  vagina  from  the  bladder  and 
rectum,  it  happens  that  vesico-vaginal  and  recto- 
vaginal fistulae  are  of  frequent  occurrence.  The 
vagina  is  very  vascular,  and  wounds  of  its  walls 
have  led  to  fatal  haemorrhage.  It  is  very  dilat- 
able, as  can  be  shown  when  the  canal  is  plugged 
to  arrest  haemorrhage  from  the  uterus. 

The  uterus  weighs  about  one  ounce.  The 
uterine  cavity  and  the  cervical  canal  together 
Q* 


490         THE    ABDOMEN    AND    THE    PELVIS    [Chap. 

measure  about  2|  inches.  This  must  be  borne  in 
mind  when  passing  a  uterine  sound.  The  blood- 
vessels run  transversely  to  the  length  of  the 
uterus,  so  that  a  ligature  may  be  placed  com- 
pletely around  the  organ  without  affecting  the 
circulation  above  or  below.  Ligature  of  the  uterine 
artery  has  been  practised  to  arrest  the  growth  of 
uterine  tumours.  The  artery  rises  from  the  in- 
ternal iliac  \  an  inch  below  the  pelvic  brim  and 
passes  to  the  neck  of  the  uterus  in  the  broad  liga- 
ment. It  is  2j  inches  long  and  loops  over  the 
ureter  midway  in  its  course.  It  is  reached  by 
incising  the  broad  ligament  between  the  Fallopian 
tube  behind  and  the  round  ligament  in  front.  It 
is  found  in  the  loose  areolar  tissue  under  the 
wound. 

The  lymphatics  from  the  fundus  of  the  uterus 
and  appendages  pass  to  the  lumbar  glands,  a  few 
also  pass  along  the  round  ligament  to  the  in- 
guinal glands.  The  lymphatics  of  the  cervix, 
which  is  frequently  the  seat  of  cancer,  pass  to 
the  internal  iliac  glands  on  the  lateral  wall  of 
the  pelvis. 

The  unimpregnated  uterus  is  very  rarely 
wounded,  owing  its  immunity  to  the  denseness  of 
its  walls,  to  its  small  size,  to  its  great  mobility, 
and  to  its  position  within  the  bony  pelvis. 

The  ovary  is  so  placed  that  the  outer  part  of 
the  Fallopian  tube  turns  downwards  externally  to 
it.  The  more  common  position  of  the  ovary  may 
be  indicated  on  the  surface  of  the  body  by  the 
line  employed  to  mark  out  the  course  of  the 
common  and  external  iliac  arteries — a  line  drawn 
from  the  aortic  bifurcation  to  the,  femoral  point 
(Fig.  72,  p.  352).  The  ovary  lies  internally  to  the 
mid-point  of  this  line  (Fig.  91,  p.  439).  It  lies 
in  the  angle  between  the  external  and  internal 
iliac  arteries,  and  may  be  indistinctly  palpated 
through  the  vagina.  Its  nerves  come  from  the 
10th  dorsal  segment  of  the  cord.  The  sensory 
nerves  for  the  cervix  are  derived  from  the  lower 
sacral    segments.     The    lymphatics    of    the    ovary 


XX]  THE    EECTUM  491 

pass  to  the  lumbar  glands,  which  lie  by  the  side 
of  the  lower  part  of  the  aorta  and  vena  cava  in 
the  retroperitoneal  tissue.  The  ovaries  exert  a 
very  marked  trophic  influence  on  the  breast;  the 
hypertrophy  of  the  mammae  at  puberty  and  in 
pregnancy  depends  on  an  internal  secretion  of 
the  ovary  (Starling).  By  their  removal  it  was 
hoped  that  cancer  of  the  breast  might  be  arrested, 
but  the  procedure  has  not  been  followed  by  much 
success.  At  the  brim  of  the  pelvis  the  ovarian 
vessels  lie  within  a  fold  of  peritoneum,  named 
the  ovario-  or  infundibulo-pelvic  ligament,  for  it 
is  attached  both  to  the  ovary  and  to  the  infundi- 
bulum  of  the  Fallopian  tube.  This  ligament 
forms  the  outer  part  of  the  pedicle  in  ovariotomy. 
The  rectum  commences  in  front  of  the  third 
sacral  vertebra,  and  is  about  5  inches  in  length 
(Fig.  98).  It  is  continuous  with  the  pelvic  colon, 
which  is  invested  by  peritoneum  and  supported 
by  a  mesentery.  The  serous  membrane  gradually 
leaves  its  posterior  surface,  then  ^  its  sides,  and 
lastly  its  anterior  surface.  Anteriorly,  the  peri- 
toneum, ^  in  the  form  of  the  recto-vesical  pouch, 
extends  in  the  male  to  within  3  inches  of  the  anus, 
while  on  the  posterior  aspect  of  the  gut  there  is 
no  peritoneum  below  a  spot  5  inches  from  the 
anus.  Thus,  in  excision  of  the  rectum,  more  of 
the  bowel  can  be  removed  on  the  posterior  than 
on  the  anterior  part  of  the  tube  without  opening 
the  peritoneal  cavity.  It  will  be  seen,  also,  that 
carcinomatous  and  other  spreading  ulcers  are 
more  apt  to  invade  the  peritoneal  cavity  when 
they  are  situated  in  the  anterior  wall  of  the 
intestine.  The  lower  part  of  the  rectum,  distin- 
guished as  the  anal  canal,  is  surrounded  by  the 
internal  sphincter— an  involuntary  muscle  con- 
tinuous with  the  circular  coat.  In  the  condition 
of  rest  the  anal  canal,  which  is  directed  down- 
wards and  backwards,  measures  lh  inches,  but 
during  defaecation  and  when  the  patient  bears 
down  it  assumes  a  shallow  annular  form.  The 
canal    is   firmly    fixed   to   the    levatores    ani    and 


492         THE    ABDOMEN    AND    THE    PELVIS     [Chap 

perineal  body,  hence  in  prolapse  it  is  the  rectum 
above  the  canal  which  is  extruded  through  the 
anus.  Mr.  Cripps  has  shown  that  the  posterior 
edge  of  the  levator  ani  forms  a  distinctly-felt 
free  border,  which  crosses  the  rectum,  nearly  at 
a  right  angle,  at  a  point  from  lj  to  2  inches 
from  the  anus. 

By    inserting   the   finger    into  the   rectum    the 


Pelvic  Colon 


Upper  Rectal   Fold 


Mid.  Rectal  Fold 

Ext.  Sphinc. 
Anal  Valves 

Anal  Columns 
Int.  Sphinc. 


Fig.  98. — The  stages  of  the  rectum  and  the  anal  canal  on 
mesial  section.     (Prof.  A,  M.  Paterson.) 

prostate  and  seminal  vesicles  can  be  readily  felt 
and  examined,  and  that  triangular  surface  of  the 
bladder  explored  through  which  puncture  per 
rectum  is  made  (p.   468). 

It  will  be  understood  that  the  prostate,  when 
enlarged,  may  encroach  upon  the  cavity  of  the 
rectum  and  greatly  narrow  its  lumen  (Fig.  95). 
The  position  of  the  seminal  vesicles  with  regard 


Bladder 

Vesic.  Semin. 
Prostate 


XX]  THE    RECTUM  493 

to  the  bowel  is  such  that  in  violent  attempts  at 
defaecation  they  may  be  pressed  upon  by  the  rectal 
contents,  and  so  in  part  emptied,  producing  a 
kind  of  spermatorrhoea.  Defaecation  also  often 
causes  much  pain  in  inflammatory  affections  of 
the  prostate  and  adjacent  parts. 

The  anterior  surface  of  the  rectum  in  the 
female  is  in  relation,  so  far  as  the  finger  can 
reach,  with  the  vagina,  and,  in  examining  the 
lower  part  of  the  rectum,  it  is  convenient  to  pro- 
trude its  mucous  membrane  through  the  anus  by 
means  of  the  finger  introduced  into  the  genital 
passage. 

The  rectum  is  dilated  and  is  very  distensible 
just  above  the  anus.  In  faecal  accumulations  it 
may  be  distended  to  a  considerable  size,  and 
strange  foreign  bodies  of  large  dimensions  have 
been  found  in  the  ampulla.  Among  the  latter 
may  be  mentioned  a  bullock's  horn,  an  iron 
match  -  box,  and  a  glass  tumbler.  By  anti- 
peristaltic movements  of  the  colon,  such  bodies 
may  be  carried  towards  the  caecum.  Thus  a  case 
has  been  reported  by  Alexander  in  which  the 
handle  of  an  umbrella,  accidentally  lodged  in  the 
rectum,  was  removed  by  the  surgeon  two  weeks 
later  from  the  hepatic  flexure  of  the  colon.  Ex- 
periment has  shown  that  when  the  rectum  is  dis- 
tended in  the  male,  the  recto-vesical  fold  of  peri- 
toneum is  raised,  and  the  bladder  is  elevated  and 
pushed  forwards.  In  the  female  the  fundus  uteri 
is  raised  and  pushed  towards  the  symphysis. 
The  rectum  is  artificially  distended  in  suprapubic 
lithotomy,  in  order  to  bring  the  bladder  into 
better  position  (p.^  465).  Normally  the  rectum  is 
empty  ^  except  during  defaecation.  Advantage  of 
this  circumstance  is  taken  in  operations  for  the 
cure  of  ectopia  vesicae  where  the  ureters  are  re- 
moved from  the  exposed  bladder  and  implanted  in 
the  rectum. 

If  the  sphincter  be  very  gradually  dilated,  the 
entire  hand,  if  small,  may  be  introduced  into  the 
rectum  in  both  males  and  females,  but  in  several 


494         THE    ABDOMEN   AND    THE    PELVIS     [Chap. 

cases,  when  so  dilated,  it  has  been  found  that  the 
sphincter  never  regains  its  normal  action.  The  cir- 
cumference of  the  hand  should  not  exceed  8  inches. 
By  a  semi-rotary  movement,  and  by  alternately 
flexing  and  extending  the  fingers,  the  hand  can  be 
insinuated  into  the  commencement  of  the  sigmoid 
flexure.  Owing  to  the  mobility  of  this  part  of 
the  bowel  a  large  extent  of  the  abdomen  may  be 
explored  through  the  bowel  wall.  The  structures 
that  can  be  readily  felt  are  the  kidneys,  the  aorta, 
the  iliac  vessels,  the  uterus  and  ovaries,  the 
bladder  and  its  surroundings,  the  pelvic  brim, 
the  sacro-sciatic  foramina,  the  ischial  spine,  the 
sacrum,  etc.  In  some  subjects  even  a  small  hand 
cannot  be  passed  beyond  the  reflection  of  the  peri- 
toneum over  the  second  part  of  the  gut.  In  such 
instances  the  peritoneum  offers  a  resistance  like  a 
tight  garter,  and  prevents  the  farther  advance  of 
the  hand  without  great  risk  of  laceration  of  the 
parts  (Walsham). 

Owing  to  the  constrained  position  of  the  hand 
and  the  cramping  of  the  fingers,  this  method  of 
examination  has  proved  to  be  of  but  limited 
service. 

The  attachments  of  the  rectum  by  means  of 
its  sheath  to  the  pelvic  fascia  are  not  very  firm ; 
fibrous  prolongations  from  the  perivascular  sheath 
accompany  the  middle  hemorrhoidal  vessels,  and 
fibrous  bands  from  the  sacrum  also  join  its  sheath. 
The  laxity  of  its  attachment  is  shown  in  some 
cases  where  the  gut  has  been  protruded  at  the 
anus.  In  excision  of  the  rectum,  also,  advantage 
is  taken  of  this  mobility. 

The  mucous  membrane  is  thick,  vascular,  and 
but  loosely  attached  to  the  muscular  coat  be- 
neath. This  laxity,  which  is  more  marked  in 
children,  favours  prolapse,  an  affection  in  which 
the  mucous  membrane  of  the  lower  part  of  the 
rectum  is  protruded  at  the  anus.  At  the  junction 
of  the  rectum  and  pelvic  colon  there  is  a  circular 
fold  or  yalve,  and  often  the  musculature  here 
is  constricted  and  apparently  forms  a  sphincter. 


XX]  THE    RECTUM  495 

Above  the  base  of  the  prostate  (Fig.  98)  the 
anterior  wall  of  the  rectum  is  folded  within  the 
lumen  of  the  gut  to  form  a  transverse  valve,  often 
named  after  Houston  who  described  it.  It  divides 
the  rectum  into  an  upper  and  lower  part.  These 
rectal  folds  or  valves ,  especially  when  the  gut 
is  empty,  may  offer  considerable  resistance  to 
the  introduction  of  a  bougie  or  long  enema  tube, 
and  their  position  should  be  therefore  borne 
in  mind. 

The  vessels,  and  especially  the  veins,  at  the 
lower  part  of  the  rectum  are  apt  to  become  vari- 
cose and  dilated,  and  form  piles.  The  tendency 
to  piles  can  in  part  be  explained  by  the  dependent 
position  of  the  rectum,  by  the  pressure  effects  of 
hardened  faeces  upon  the  returning  veins,  and  by 
the  fact  that  part  of  the  venous  blood  returns 
through  the  systemic  system  (internal  iliac  vein) 
and  part  through  the  portal  system  (inferior 
mesenteric  vein).  This  connexion  with  the  portal 
trunk,  which  is  not  an  extensive  one,  may 
cause  the  rectum  to  participate  in  the  many 
forms  of  congestion  incident  to  that  vein.  The 
veins  of  the  rectum  can  also  be  affected  by 
violent  expiratory  efforts.  For  the  last  4  inches 
of  the  bowel,  moreover,  the  arrangement  of  the 
vessels  is  peculiar,  and  is  such  as  to  favour  vari- 
cosity. The  arteries,  u  having  penetrated  the 
muscular  coats  at  different  heights,  assume  a 
longitudinal  direction,  passing  in  parallel  lines 
towards  the  edge  of  the  bowel.  In  their  progress 
downwards  they  communicate  with  one  another  at 
intervals,  and  they  are  very  freely  connected  near 
the  orifice,  where  all  the  arteries  join,  by  trans- 
verse branches  of  considerable  size."  (Quain.) 
The  branches  of  the  superior  hemorrhoidal  ar- 
teries terminate  in  the  submucous  tissue  of  the 
anal  canal,  forming  vascular  columns  which 
extend  to  the  anus.  The  veins  form  a  plexus 
with  a  precisely  similar  arrangement.  The  veins 
beneath  the  mucous  membrane  of  the  anal  canal 
perforate  the  muscular  coat  of  the  rectum  about 


496         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

1  inch  above  the  anal  canal.  At  the  point  of 
perforation  they  are  liable  to  be  compressed. 

The  lymphatics  of  the  rectum  perforate  the 
muscular  coat  and  ascend  in  its  sheath,  where, 
on  the  posterior  aspect,  there  may  be  one  or 
more  glands.  They  join  the  efferent  vessels  of 
the  colon  in  the  mesentery  of  the  pelvic  colon. 
They  also  pass  to  the  internal  iliac  group  of 
lymphatic  glands  on  the  lateral  wall  of  the  pelvis 
and  to  the  lumbar  glands.  Hence  in  cancer  of 
the  lower  part  of  the  rectum  these  glands  and 
the  vessels  leading  to  them  are  the  earliest  seats 
of  secondary  infections.  The  lymphatics  of  the 
pelvic  colon  pass  to  the  glands  in  front  of 
the  sacrum  and  to  others  between  the  layers 
of  the  meso-rectum. 

The  rectum  may  be  most  freely  exposed  from 
behind  (Figs.  94  and  98).  In  Kraske's  operation 
for  the  extirpation  of  cancer  of  the  rectum  an 
incision  is  made  along  the  sacrum  in  the  middle 
line,  from  the  level  of  the  posterior  inferior  iliac 
spine  to  the  anus.  A  flap  is  turned  out  on  the  left 
side,  including  the  skin  and  origin  of  the  gluteus 
maximus.  The  attachments  of  the  left  sacro-sciatic 
ligaments,  coccygeus,  and  levator  ani  to  the  sacrum 
and  coccyx  are  divided  and  turned  outwards. 
The  lateral  and  median  sacral  arteries  and  a 
plexus  of  veins  are  raised  with  the  fibrous  tissue 
from  the  anterior  surface  of  the  sacrum  by  a 
periosteal  elevator.  The  left  halves  of  the  4th 
and  5th  sacral  vertebrae,  with  the  left  half  of 
the  coccyx,  are  removed.  The  4th,  5th  sacral, 
and  coccygeal  nerves  are  necessarily  cut,  but  an 
attempt  should  be  made  to  save  the  3rd  sacral 
nerve,  owing  to  the  importance  of  its  function. 
The  rectum  is  then  exposed,  with  the  hsemor- 
rhoidal  vessels  and  reflection  of  peritoneum.  By 
opening  the  peritoneal  cavity  part  of  the  pelvic 
colon  may  be  brought  into  the  wound.  After  the 
diseased  part  is  removed,  with  the  presacral  and 
internal  iliac  lymphatic  glands,  the  upper  end  of 
the  rectum  is  brought  down  and  sutured  to  the 


XX]  THE    ANUS  497 

anal  part.  An  attempt  should  be  made  to  save 
the  levator  ani  and  3rd  sacral  nerve,  in  order 
that  the  integrity  of  the  pelvic  diaphragm  may 
be  maintained.  For  a  complete  removal  of 
secondary  deposits  in  the  lymphatic  system  of 
the  rectum,  the  sacral  operation  is  usually  com- 
bined with  an  abdominal  section.  The  rectum 
is  supplied  with  sensory  and  motor  nerves  from 
the  2nd,  3rd,  and  4th  sacral  segments  through 
the  corresponding  nerves.  Some  motor  nerves  are 
also  derived  from  the  lower  two  dorsal  and  upper 
lumbar  segments.  These  nerves  reach  the  rectum 
through  the  hypogastric  and  pelvic  plexuses. 

The  anus. — The  skin  about  the  anus  is  thrown 
into  numerous  folds,  and  in  these  ulcer  or  fis- 
sure of  the  anus  forms.  Within  the  anal  canal 
the  mucous  membrane  is  thrown  into  vertical 
folds — the  columns  of  Morgagni.  When  the  canal 
is  dilated  they  are  obliterated,  and  as  age  ad- 
vances they  become  less  well  marked.  As  is  shown 
in  Figs.  93  and  98,  the  columns  end  above  at 
the  junction  of  canal  and  rectum.  Between  their 
upper  extremities  are  small  recesses,  which  Sir 
Charles  Ball  describes  as  the  sinuses  of  Morgagni, 
and  over  them,  joining  the  upper  ends  of  the 
columns,  are  little  folds  of  mucous  membrane — 
the  anal  valves.  When  the  anal  canal  is  closed, 
the  columns  and  valves  come  together  and  so 
make  the  anal  orifice  competent.  The  valves  may 
be  torn  by  the  passing  scybalous  masses,  and 
from  the  rent  thus  caused  a  fissure  of  the  anus 
may  be  produced  (Ball).  The  extreme  painful- 
ness  of  these  ulcers  is  due  to  the  exposure  of  a 
nerve  fibre  at  their  base,  and  to  the  constant  con- 
traction of  the  sphincter  muscle  that  they  excite. 
In  90  per  cenk  of  cases  of  pruritus  ani*  there  is 
a  small  ulcer  in  the  posterior  wall  of  the  anal 
canal,  near  the  anal  valves  (F.  C.  Wallis).  Relief 
is  given  by  excising  the  base  of  the  ulcer,  so  as 
to  divide  some  part  of  the  sphincter;  or  by 
violently  dilating  the  anus,  so  as  to  tear  up  the 
base   of  the   ulcer   and   paralyse   for  a  while  the 


498         THE    ABDOMEN    AND    THE    PELVIS     [Chap. 

action  of  the  disturbing  muscle.  The  anal  canal 
is  lined  with  a  stratified  mucous  membrane 
derived  from  an  invagination  or  ingrowth  of  the 
epiblast  or  embryonic  epiderm.  The  rectum,  on 
the  other  hand,  is  lined  with  mucous  columnar 
epithelium  derived  from  the  hypoblast  of  the 
hind  gut  of  the  embryo.  The  junctional  line  is 
at  the  upper  ends  of  the  columns  of  Morgagni. 
At  their  lower  ends  the  mucous  membrane  joins 
the  skin,  the  junction  being  sometimes  marked  by 
a  faint  white  line. 

The  anus  may  be  torn  during  defaecation  when 
the  stools  are  hard.  A  case  is  reported  of  a 
woman  who,  during  violent  efforts  at  defsecation, 
felt  something  give  way,  and  discovered  faeces  in 
her  vagina.  The  recto-vaginal  wall  had  ruptured 
2  inches  from  the  anus.  During  labour  the  child's 
head  has  passed  into  the  rectum,  and  has  been 
delivered  per  anum. 

An  imperforate  anus  is  the  most  common  con- 
genital defect  of  the  rectum.  This  condition 
represents  an  arrest  of  development.  The  forma- 
tion of  the  anus  is  a  double  process  :  first  there  is 
an  ingrowth  from  the  perineum,  and  secondly  a 
downgrowth  from  the  bowel,  these  two  elements 
meeting  and  communicating  at  the  upper  end 
of  the  anal  canal.  In  many  cases  of  imperforate 
anus,  only  a  thin  anal  membrane  requires  to  be 
broken  down  to  allow  the  free  passage  of  faeces; 
but  in  other  cases  the  defect  is  much  greater,  the 
anal  canal,  and  even  the  rectum,  being  completely 
wanting.  Not  infrequently  in  such  cases  the 
rectum  may  communicate  with  the  urethra  in 
the  male  or  with^  the  vulval  cleft  in  the  female. 
This  communication  is  due  to  the  persistence  of 
an  embryonic  condition.  In  Fig.  99  is  given  a 
diagrammatic  representation  of  the  manner  in 
which  the  rectum  terminated  in  fifty-four  museum 
specimens  of  imperforate  anus.  In  more  than 
half  of  these  specimens — all  of  which  were  males 
— the  rectum  terminated  at  the  lower  part  of  the 
prostate.     In    the    female    it    may    terminate    at 


XX] 


PELVIC    AND    PERINEAL    NEKVES 


499 


any  point  of  the  vagina  or  open  in  the  vulval 
cleft.  The  proctodaeal  invagination  to  form  the 
anal  canal -may  be  incompletely  formed  or  absent, 
but  a  sphincter  is  always  present.* 

Nerves   of   Pelvis   and   Perineum 

The  pelvic  viscera  are  supplied  by  the  pelvic 
plexus  of  the  sympathetic.     This  is  joined  by  at 


7  Specimens 


33  Specimens 


7  Specimens 


•  7  Specimens 
Septum 

Anal  Canal 


Fig.  99. — Diagram  to  show  the  manner  in  which  the  rectum 
terminated  in  54  cases  of  imperforate  anus  in  the  male. 

least  three  spinal  nerves,   the  2nd,   3rd,   and  4th 
sacraL 

It  is  well  known  that  in  certain  affections  of 
the  bladder,   rectum,   prostate,   etc.,   pain   is  felt 

*  See  Keith,  Brit.  Med.  Journ.,  Dec,  1908. 


500         THE    ABDOMEN   AND    THE    PELVIS     [Chap. 

along  the  perineum,  in  the  penis,  over  the  but- 
tock, and  down  the  thigh.  These  parts  are  sup- 
plied by  the  pudic  and  small  sciatic  nerves,  and 
the  reason  for  the  pain  is  explained  by  the  origin 
of  the  sensory  nerves  for  those  organs  from  the 
same  and  adjoining  segments  of  the  spinal  cord. 
The  upper  part  of  the  rectum  is  provided  with 
but  little  sensation,  as  illustrated  by  the  passage 
of  instruments,  by  the  comparative  painlessness 
of  malignant  and  other  growths  high  up  in  the 
bowel,  and  by  the  little  inconvenience  felt  when 
the  gut  is  distended  with  hardened  fseces.  From 
this  apathy  it  has  probably  happened  that,  in 
the  self-administration  of  enemata,  patients  have 
thrust  the  tube  through  the  rectum  into  the  peri- 
toneal cavity.  The  anal  canal,  on  the  other  hand, 
is  extremely  sensitive. 

The  nerve  relations  between  the  anus  and  the 
neck  of  the  bladder  are  very  intimate.  Painful 
affections  of  the  anus  often  cause  bladder  troubles, 
and  retention  of  urine  is  very  common  after 
operations  upon  piles.  Maladies,  on  the  other 
hand,  that  involve  the  bladder  neck  are  often 
associated  with  tenesmus  and  anal  discomfort. 
This  relation  is  maintained  by  the  pelvic  plexus, 
but  mainly  by  the  4th  sacral  nerve.  This  nerve 
gives  special  branches  direct  to  the  neck  of  the 
bladder,  and  then  goes  to  supply  the  muscles 
of  the  anus  (the  sphincter  and  levator)  and  the 
integument  between  the  anus  and  the  coccyx. 

The  mucous  membrane  of  the  urethra,  the 
muscles  of  the  penis,  and  the  greater  part  of 
the  skin  of  the  penis,  scrotum,  perineum,  and 
anus,  are  supplied,  from  the  2nd,  3rd,  and  4th 
sacral  segments,  by  the  pudic  nerve.  Thus,  it 
will  be  understood  that  irritation  applied  to  the 
urethra  may  cause  erection  of  the  penis  (as  illus- 
trated by  chordee  in  gonorrhoea),  or  may  produce 
contraction  of  the  urethral  muscles  (as  seen  in 
some  forms  of  spasmodic  stricture).  The  disturb- 
ance caused  by  accumulated  secretion  beneath  the 
prepuce    in    young   children    may    provoke    great 


XX]  PELVIC    AND    TERINEAL    NERVES  501 

irritability  of  the  organ,  and  it  is  well  known 
that  painful  affections  of  the  perineum  and  anus 
may  be  associated  with  priapism.  The  distribu- 
tion of  the  3rd  sacral  segment  in  the  perineum 
by  means  of  the  long  pudendal  nerve  will  explain 
the  pain  about  the  buttock  and  down  the  back  of 
the  thigh  that  is  often  complained  of  during  the 
growth  of  perineal  abscess  and  in  painful  affec- 
tions of  the  scrotum.  This  nerve  crosses  just  in 
front  of  the  tuber  ischii,  and  may  be  so  pressed 
upon  b^  using  a  hard  seat  as  to  cause  one-sided 
neuralgia  of  the  penis  and  scrotum.  It  is  also 
in  close  connexion  with  the  ischial  bursa,  and 
neuralgia  of  the  same  parts  has  been  met  with  in 
cases  of  inflammation  involving  that  structure. 

The  testicle  is  supplied  mainly  from  the  10th 
dorsal  segment  by  the  spermatic  plexus.  The  kid- 
ney is  also  partly  supplied  from  the  same  segment. 
This  is  illustrated  by  the  pain  felt  in  the  renal 
region  during  neuralgia  of  the  testicle,  and  by  the 
pain  felt  in  the  testicle,  the  vigorous  retraction 
of  that  organ  observed  in  certain  affections  of  the 
kidney,  such  as  in  acute  nephritis,  and  in  the 
passage  of  renal  calculi.  By  means  of  the  renal 
plexus  the  testicle  is  brought  into  direct  com- 
munication with  the  semilunar  ganglia  and  solar 
plexus,  which  receives  some  of  the  terminal  fibres 
of  the  vagus.  This  communication  may  serve  to 
explain  the  great  collapse  often  noticed  in  sudden 
injuries  to  the  testicle,  and  especially  the  marked 
tendency  to  vomit,  .  so  often  observed  in  such 
lesions.  #  So  far  as  its  nerves  are  concerned,  the 
testicle  is  nearly  in  as  intimate  relation  with  the 
great  nerve-centre^  of  the  abdomen  as  is  a  great 
part  of  the  small  intestine,  and  one  would  expect 
a  sudden  crush  of  the  testis  to  be  associated  with 
as  severe  general  symptoms  as  would  accompany 
a  sudden  nipping  of  the  ileum  in  a  rupture. 
Such  a  resemblance  in  symptoms  is  actually  to  be 
observed  in  practice. 


PARTV.-THE  LOWER  EXTREMITY 

CHAPTER  XXI 

THE    REGION    OF    THE    HIP 

This  region  will  be  considered  under  the  follow- 
ing heads  :  1.  The  buttocks.  2.  The  region  of 
Scarpa's  triangle.  3.  The  hip-joint,  with  the 
upper  third  of  the  femur. 

1.   The  Buttocks 

Surface  anatomy. — The  bony  points  about 
the  gluteal  region  can  be  well  made  out.  The 
crest  of  the  ilium  is  distinct,  as  is  also  the 
anterior  superior  spine.  The  posterior  superior 
spine  is  less  evident,  but  can  be  readily  felt  by 
following  the  crest  to  its  posterior  termination. 
This  spine  is  on  a  level  with  the  second  sacral 
spine,  and  is  placed  just  behind  the  centre  of  the 
sacro-iliac  articulation.  The  great  trochanter  is 
a  conspicuous  landmark.  It  is  covered  by  the 
fascial  insertion  of  the  gluteus  maximus.  Its 
upper  border  is  on  a  level  with  the  centre  of  the 
hip-joint,  and  is  somewhat  obscured  by  the  tendon 
of  the  gluteus  medius  which  passes  over  it.  The 
comparatively  slight  prominence  of  the  trochanter 
in  the  living  subject,  as  compared  with  the  great 
projection  it  forms  in  the  skeleton,  depends  upon 
the  completeness  with  which  the  gluteus  medius 
502 


Chap.  XXI]  THE    BUTTOCK  503 

and  minimus  fill  up  the  hollow  between  the  tro- 
chanter and  the  ilium.  When  these  muscles  are 
atrophied  the  process  becomes  very  conspicuous. 
In  fat  individuals  its  position  is  indicated  by  a 
slight  but  distinct  depression  over  the  hip. 

If  a  line  be  drawn  from  the  anterior  superior 
spine  to  the  most  prominent  part  of  the  tuber 
ischii,  it  will  cross  the  centre  of  the  acetabulum, 
and  will  hit  the  top  of  the  trochanter.  This  line, 
known  as  Nelaton's  line,  is  frequently  made  use 
of  in  the  diagnosis  of  certain  injuries  about  the 
hip.  McCurdy  prefers  a  line  drawn  from  the 
pubic  spine  at  a  right  angle  to  the  median  line 
of  the  body ;  if  the  femur  is  normal  in  position 
the  pubic  line  should  cross  at  or  just  above  the 
great  trochanter.  The  mid-point  of  this  line  lies 
over  the  head  of  the  femur.  The  anterior  superior 
spine  or  crest  of  the  ilium  may  be  used  as  fixed 
points  from  which  to  estimate  the  degree  of  dis- 
placement of  the  great  trochanter. 

The  ischial  tuberosities  are  readily  felt.  They 
are  covered  by  the  fleshy  fibres  of  the  gluteus  maxi- 
mus  when  the  hip  is  extended.  But  when  the  hip 
is  flexed,  the  processes  become  to  a  great  extent 
uncovered  by  that  muscle.  The  muscular  mass  of 
the  buttock  is  formed  by  the  gluteus  maximus  be- 
hind and  by  the  gluteus  medius  and  minimus  and 
tensor  vaginae  femoris  in  front.  The  last-named 
muscle  can  be  seen  when  in  action,  i.e.  when  the 
thigh  is  abducted  and  rotated  in. 

The  fold  of  the  buttock  crosses  the  obliquely 
placed  lower  border  of  the  gluteus  maximus. 
When  the  hip  is  fully  extended,  as  in  the  erect- 
posture,  the  buttocks  are  round  and  prominent, 
the  gluteal  fold  is  transverse  and  very  distinct. 
When  the  hip  is  a  little  flexed,  the  buttocks  be- 
come flattened,  the  gluteal  fold  becomes  oblique 
and  then  disappears.  Among  the  early  symptoms 
of  hip  disease  are  flattening  of  the  buttock  and 
loss  of  the  gluteal  fold.  These  symptoms  depend 
upon  the  flexion  of  the  hip,  which  is  practically 
constant  in  every  case  of  the  malady  before  treat- 


504  THE    LOWER    EXTREMITY  LChap. 

merit.  It  is  incorrect  to  say,  as  some  books  still 
assert,  that  these  changes  are  due  to  wasting  of 
the  gluteal  muscles,  since  they  appear  at  too  early 
a  period  for  any  considerable  muscular  atrophy 
to  have  taken  place.  It  is  true  that  these  symp- 
toms are  much  exaggerated  by  the  wasting  of 
the  muscle  that  occurs  later  on  in  the  course 
of  the  hip  affection. 

With  regard  to  the  vessels  and  nerves  of  the 
buttock,  if  a  line  be  drawn  from  the  posterior 
superior  spine  to  the  top  of  the  great  trochanter 
when  the  thigh  is  rotated  in,  a  point  at  the  junc- 
tion of  the  inner  with  the  middle  third  of 
that  line  will  correspond  to  the  gluteal  artery 
as  it  emerges  from  the  sciatic  notch.  A  line 
drawn  from  the  posterior  ^  superior  spine  to  tin 
outer  part  of  the  tuber  ischii  crosses  both  the 
posterior  inferior  and  ischial  spines  (Fig.  100). 
The  former  is  about  2  inches  and  the  latter  about 
4  inches  below  the  posterior  superior  process.  The 
sciatic  artery  reaches  the  gluteal  region  at  a  spot 
corresponding  to  the  junction  of  the  middle  with 
the  lower  third  of  this  line.  The  position  of  the 
pudic  artery  as  regards  the  buttock  is  not  difficult 
to  indicate,  since  it  crosses  over  the  ischial  spine 
in  passing  from  the  great  to  the  small  sacro- 
sciatic  foramen.  The  sciatic  nerve  is  most  easily 
found  as  it  escapes  from  beneath  the  gluteus  maxi- 
mus.  When  the  thigh  is  rotated  outwards,  so  that 
the  great  trochanter  approaches  the  ischial  tuber- 
osity, the  nerve  lies  midway  between  these  two 
bony  points,  but  in  the  unrotated  position  it  is 
found  at  the  junction  of  the  inner  and  middle 
thirds  of  a  line  joining  them. 

The  skin  over  the  buttock  is  thick  and  coarse, 
and  is  frequently  the  seat  of  boils.  From  the 
appearance  it  presents  in  very  fully  injected  speci- 
mens, it  would  appear  that  the  blood  supply  is 
not  quite  so  free  as  it  is  in  many  other  parts  of 
the  surface. 

The  subcutaneous  fascia  is  lax,  and  contains 
a  large  quantity  of  fat.     It  is  to  this  fat  rather 


XXI]  THE   BUTTOCK  605 

than  to  muscular  development  that  the  buttock 
owes  its  roundness  and  prominence.  The  enor- 
mous buttocks  of  the  so-called  "  Hottentot  Venus," 
whose  model  is  in  many  museums,  depend  for 
their  unusual  dimensions  upon  the  greatly  in- 
creased subcutaneous  fat.  The  amount  of  adipose 
tissue  normally  in  the  part  renders  the  buttock 
a  favourite  place  for  lipomata.  The  laxity  of  the 
superficial  fascia  permits  large  effusions,  both  of 
blood  and  pus,  to  take  place  in  the  gluteal  region, 
and  ecchymoses  of  the  buttock  can  probably  reach 
a  greater  magnitude  in  this  district  than  is 
possible  elsewhere. 

The  deep  fascia  of  the  buttock,  a  part  of 
the  fascia  lata  of  the  thigh,  is  a  structure  of  much 
importance.  This  dense  membrane  is  attached 
above  to  the  iliac  crest,  and  to  the  sacrum  and 
coccyx.  Descending  in  front  over  the  gluteus 
medius,  it  splits  on  reaching  the  anterior  edge  of 
the  gluteus  maximus  into  two  layers,  one  of  which 
passes  in  front  of  the  muscle  and  the  other  behind. 
The  gluteus  maximus  is  thus  enclosed,  like  the 
meat  in  a  sandwich,  between  two  layers  of  fascia, 
and  the  two  lesser  gluteal  muscles  are  bound  down 
within  an  osseo-aponeurotic  space,  which  is  firmly 
closed  above,  and  only  open  below  towards  the 
thigh  and  internally  at  the  sciatic  foramina.  Ex- 
travasations of  blood  may  take  place  beneath  this 
fascia  without  any  discoloration  of  the  skin  to  in- 
dicate the  fact,  the  blood  being  unable  to  reach 
the  surface  through  the  dense  membrane.  Such 
extravasations  may  be  long  pent  up,  and,  as  they 
fluctuate,  may  be  mistaken  for  abscess. 

Deep  inflammations  beneath  this  fascia,  and 
especially  when  beneath  the  gluteus  medius,  may 
be  associated  with  much  pain,  owing  to  the  cir- 
cumstance that  the  inflammatory  effusions  will  be 
pent  up  between  a  wall  of  bone  on  one  side  and 
a  wall  of  dense  fascia  and  stout  muscle  on  the 
other.  Abscesses  so  pent  up  may  travel  for  a  con- 
siderable distance  down  the  thigh  before  they 
reach   the   surface,    and   Farabeuf   relates   a  case 


506  THE    LOWER    EXTREMITY  [Chap. 

where  a  gluteal  abscess  travelled  to  the  ankle 
before   it  broke. 

In  other  circumstances  the  gluteal  abscess 
may  make  its  way  into  the  pelvis  through  the 
sciatic  foramina,  or  a  pelvic  abscess  may  escape 
through  one  of  these  foramina  and  appear  as  a 
deep  abscess  of  the  buttock. 

The  thickened  part  of  the  fascia  lata  that  runs 
down  on  the  outer  side  of  the  limb  between  the 
crest  of  the  ileum  above  and  the  outer  tuberosity 
of  the  tibia  and  head  of  the  fibula  below,  is 
known  as  the  ilio-tibial  band.  This  band  is  tightly 
stretched  across  the  gap  between  the  iliac  crest 
and  the  great  trochanter,  and  if  pressure  be  made 
with  the  fingers  between  these  two  points,  the  re- 
sistance of  this  part  of  the  fascia  can  be  appreci- 
ated. It  is  obvious  that  in  fracture  of  the  neck 
of  the  femur,  when  the  great  trochanter  is  made 
to  approach  nearer  to  the  crest,  this  band  will 
become  relaxed,  and  Dr.  Allis^  (Agnew's  "  Sur- 
gery/7 vol.  i.)  has  drawn  attention  to  this  fascial 
relaxation  as  of  value  in  the  diagnosis  of  frac- 
tures of  the  femoral  neck. 

The  lower  free  edge  of  the  gluteus  maximus 
is  oblique,  and  ends  some  way  below  the  transverse 
line  of  the  fold  of  the  buttock. 

It  would  appear  that  even  this  great  muscle 
may  be  ruptured  by  violence.  Thus  Dr.  Mac- 
Donnell  (Brit.  Med.  Joum.,  1878)  reports  the  case 
of  a  robust  man  aged  63,  who,  while  trying  to 
lift  a  heavy  cart  when  in  a  crouching  position, 
felt  something  give  way  in  his  buttock,  and 
heard  a  snap.  He  fell,  and  was  carried  home, 
when  it  was  found  that  the^  great  gluteal  muscle 
was  ruptured  near  the  junction  of  the  muscle  with 
its  tendon. 

At  least  three  bursae  exist  over  the  great 
trochanter,  separating  that  process  from  the  three 
gluteal  muscles  respectively.  The  most  extensive 
is  that  between  the  insertion  of  the  gluteus  maxi- 
mus to  the  ilio-tibial  band  and  outer  surface  of 
the  great  trochanter.     The  bursa  allows  the  great 


XXI]  THE    BUTTOCK  507 

trochanter  to  move  freely  beneath  the  muscle 
during  rotation  of  the  thigh.  When  this  sac  is 
inflamed  much  difficulty  is  experienced  in  moving 
the  limb,  and  the  thigh  is  generally  kept  flexed 
and  adducted.  This  position  means  absolute  rest 
from  movement  on  the  part  of  the  gluteal  muscles, 
which,  when  acting,  would  extend  and  abduct 
the  limb,  and  bring  pressure  to  bear  upon  the 
tender  bursa. 

There  is  a  bursa  over  the  ischial  tuberosity 
that  is  often  inflamed  in  those  whose  employments 
involve  much  sitting,  the  bursa  being  directly 
pressed  upon  in  that  position.  This  sac  is  the 
anatomical  basis  of  the  disease  known  in  older 
text-books  as  "weaver's  bottom  "  or  "  lighter- 
man's bottom."  #  When  enlarged  this  bursa  may 
press  upon  the  inferior  pudendal  nerve. 

Arteries  and  nerves  of  the  buttock.  — 
The  gluteal  artery  is  about  the  same  size  as  the 
ulnar,  and  the  sciatic  as  the  lingual.  The  former 
vessel  may  sometimes  be  of  much  greater  mag- 
nitude, and  has  led,  when  wounded,  to  rapid 
death  from  haemorrhage.  Wounds  of  the  gluteal 
vessels  will  probably  involve  only  the  branches  of 
the  artery,  since  the  greater  part  of  the  main 
trunk  is  situate  within  the  pelvis.  Gluteal  aneu- 
rysms are  not  very  uncommon,  and  with  regard  to 
the  treatment  of  these  tumours  it  may  be  noted 
that  the  gluteal  artery,  or,  better,  the  internal 
iliac  trunk,  can  be  compressed  through  the  rectum. 
Compression  so  applied  has  been  adopted  for  the 
treatment  of  gluteal  aneurysm  by  Dr.  Sands,  of 
New  York  (Amer.  Journ.  Med.  Set.,  1881),  but 
without  much  effect.  Aneurysm  of  the  commence- 
ment of  the  gluteal  artery  could  hardly  fail  to 
provoke  nerve  symptoms,  since  the  vessel  runs  be- 
tween the  lumbo-sacral  cord  and  1st  sacral  nerve. 

Both  the  gluteal  and  sciatic  arteries  have  been 
ligatured  in  the  buttock,  through  incisions  made 
directly  over  the  course^  of  the  vessels. 

Henle  has  collected  six  cases  where  the  femoral 
artery  ran  down  along  the  back  of  the  thigh  to 


508 


THE    LOWER    EXTREMITY 


[Chap. 


the  popliteal  space  in  company  with  the  great 
sciatic  nerve.  The  abnormal  vessel  was  in  each 
case  formed  by  an  enlargement  of  the  comes  nervi 
ischiadici,  a  branch  of  the  sciatic  artery. 

The  great  sciatic  nerve  is  a  continuation 
downwards  of  the  main  part  of  the  sacral  plexus 
(Fig.  100).  It  is  in  this  nerve  that  the  form  of 
neuralgia  known  as  sciatica  is  located.  A  reference 


Post.  Sup.  Spine 


Lfsser  Sacro-Sciatic  Liq. 
Cheat  Sacro  Sciatic  Liq. 


Fig.  100. — Formation  and  relationships  of  the  upper  part 
of  the  great  sciatic  nerve. 


to  the  immediate  relations  of  this  nerve  will  show 
that  it  may  readily  be  exposed  to  many  external 
influences.  Thus,  in  the  pelvis  it  may  be  pressed 
upon  by  various  forms  of  pelvic  tumour,  and 
sciatica  Jbe  produced  in  consequence.  Its  anterior 
surface  is  in  close  relation  with  some  of  the  princi- 
pal pelvic  veins,  and  according  to  Erb  one  form 
of  sciatica  may  be  traced  to  an  engorged  condi- 
tion of  these  vessels.  Aneurysm  of  certain  branches 
of   the   internal    iliac   artery   within    the    pelvis, 


XXI]  THE    BUTTOCK  509 

sciatic  hernia,  and  accumulation  of  faeces  within 
the  rectum  may  all  cause  neuralgia  of  this  im- 
portant trunk.  It  is  said  to  have  been  injured 
also  by  the  pressure  of  the  foetal  head  during 
tedious  labours,  and  to  be  affected  by  violent 
movements  of  the.  hip,  a  circumstance  readily 
understood  if  the  close  relation  of  the  nerve  to 
the  hip-joint  be  borne  in  mind.  The  nerve  is  also 
near  enough  to  the  surface  to  be  influenced  by 
external  cold,  and  to  this  influence  many  forms 
of  sciatica  are  ascribed.  At  the  lower  edge  of 
the  great  gluteal  muscle  the  trunk  is  still  nearer 
to  the  surface,  and  this  fact  receives  illustration 
in  a  case  reported  in  Ziemssen's  Cyclopaedia, 
where  paralysis  of  the  nerve  followed  its  com- 
pression by  the  contracting  scar  of  a  bed-sore. 

Nerve  stretching  and  injecting.  —  The  great 
sciatic  nerve  has  been  frequently  cut  down  upon 
and  stretched  for  the  relief  of  certain  nervous 
affections  of  the  limb  (see  p.  604).  In  connexion 
with  this  procedure  it  is  important  to  know  how 
great  an  amount  of  traction  may^  be  brought  to 
bear  upon  this  and  other  nerves  withoutthe  cord 
giving  way.  Trombetta,  who  has  paid  much 
attention  to  this  matter,  gives  the  following 
weights  as  those  required  >  to  break  the;  under- 
mentioned nerves  :  great  sciatic,  183  lb. ;  internal 
popliteal,  114  lb.  ;  anterior  crural,  83  lb. ;  me- 
dian, 83  lb.  ;  ulnar  and  radial,  59  lb.  ;  brachial 
plexus  in  the  neck,  48  to  63  lb. ;  and  brachial 
plexus  in  the  axilla,  35  to  81  lb.  (In  each  in- 
stance fractions  have  been  omitted.)  It  must  be 
borne  in  mind,  however,  as  pointed  out  by  Mr. 
Symington  {Lancet,  1878),  that  in  forcibly  stretch- 
ing the  great  sciatic  nerve  the  trunk  may  be  torn 
away  from  its^  attachments  to  the  soft  spinal  cord 
before  a  sufficient  force  has  been  applied  to  rup- 
ture the^  nerve  at  the  point  stretched.  The  same 
observation  applies  to  other  large  nerve-cords, 
such  as  those  of  the  brachial  plexus,  that  are 
stretched  at  a  spot  not  far  from  their  spinal  con- 
nexions.    The  great  sciatic  nerve  may  be  stretched 


510  THE    LOWER    EXTREMITY  [Chap. 

by  flexing  the  extended  lower  extremity  on  the 
belly.  This  measure  has  served  to  cure  certain 
cases  of  sciatica.  For  the  hypodermic  injection 
of  the  great  sciatic  nerve  to  relieve  sciatica,  the 
needle  is  inserted  to  penetrate  the  nerve  as  it 
lies  on  the  bone  below  the  great  sacro-sciatic 
notch.  This  point  is  best  found  by  a  guide  line 
drawn  from  the  posterior  superior  iliac  spine  to 
the  ischial  tuberosity.  If  the  point  of  the  needle 
be  inserted  I  an  inch  externally  to  the  junction 
of  the  middle  and  Jower  thirds  of  this  line,  it 
lies  directly  over  the  nerve  (Fig.  100).  The  nerve 
is  here  covered  by  the  gluteus  maximus,  and  lies 
on  the  ischium  between  the  pyriformis  above  and 
the  obturator  internus  below. 

The  skin  of  the  buttock  is  well  supplied  with 
nerves,  and  tactile  sensibility  is  almost  as  acute 
in  this  part  as  it  is  over  the  back  of  the  hand, 
while  it  is  more  acute  than  is  like  sensibility 
in  such  parts  as  the  back  of  the  neck,  the  middle 
of  the  thigh,  and  the  middle  of  the  back.  The 
sensation  of  the  gluteal  integument  is  derived 
from  a  number  of  different  nerves,  and  it  may 
possibly !  interest  a  school-boy  who  has  been  re- 
cently birched  to  know  that  the  painful  sensations 
reached  his  sensorium  through  some  or  all  of  the 
following  nerves  :  offsets  of  the  posterior  branches 
of  the  lumbar  nerves,  some  branches  of  the  sacral 
nerves,  the  lateral  cutaneous  branch  of  the  last 
dorsal  nerve,  the  iliac  branch  of  the  ilio-hypo- 
gastric  nerve,  offsets  of  the  external  cutaneous 
nerve,  and  large  branches  of  the  small  sciatic. 
These  nerves  are  derived  from  four  spinal  seg- 
ments— the  12th  dorsal,  1st  lumbar,  2nd  and  3rd 
sacral  (Fig.  133,  p.  623).  The  2nd  and  3rd  sacral 
also  supply  the  sexual  organs,  hence  the  physio- 
logical effects  which  may  follow  application  of 
punishment  to  this  part,  as  in  the  celebrated  case 
of  J.   J.  Rousseau. 

It  should  be  remembered  that  the  pelvic  vis- 
cera can  be  readily  reached  through  the  sciatic 
foramina  from  the  buttock.     I  once  saw  a  case  at 


XXI]  SCABPA'S    TRIANGLE  511 

the  London  Hospital  of  a  man  who  was  admitted 
with  an  apparently  insignificant  stab  of  the  but- 
tock. He  died  in  a  few  days,  of  acute  peritonitis ; 
and  the  autopsy  showed  that  the  dagger  had 
passed  through  the  great  sacro-sciatic  foramen, 
had  entered  the  bladder  and  allowed  urine  to 
escape  into  the  peritoneal  cavity.  The  rectum 
has  also  been  damaged  in  injuries  to  the  buttock, 
and  Anger  records  a  case  of  an  artificial  anus 
situate  upon  the  buttock,  that  had  followed  a  gun- 
shot wound,  which,  after  involving  the  buttock, 
had  opened  up  the  caecum.  It  is  by  this  route  that 
Kraske's  operation  for  resection  of  the  rectum 
is  performed  and  Bigby's  operation  on  the  ureter. 

2.   The  Region  of  Scarpa's  Triangle 

Surface  anatomy.— The  most  important  land- 
marks in  the  region  of  the  groin,  the  anterior 
superior  iliac  spine,  the  spine  of  the  pubes,  and 
Poupart's  ligament,  are  readily  made  out.  To 
the  two  spines  reference  has  already  been  made 
(p.  502).  Poupart's  ligament  follows  a  curved 
line,  with  its  convexity  downwards,  drawn  be- 
tween these  two  projections.  It  can  be  felt  in 
even  stout  persons,  its  inner  half  more  distinctly 
than  its  outer,  and  even  in  very  fat  individuals  its 
position  is  indicated  by  a  slight  furrow.  Owing 
to  its  attachment  to  the  fascia  lata  the  ligament 
is  relaxed,  and  rendered  less  distinct  when  the 
thigh  is  flexed  and  adducted,  or  when  it  is  rotated 
in.  The  mid-point  of  a  line  joining  the  pubic 
with  the  anterior  superior  spine  lies  over  the 
head  of  the  femur  and  hip-joint.  In  this  position 
a  crease  is  often  to  be  seen  crossing  the  groin 
(Holden). 

The  sartorius  muscle  is  brought  into  view  when 
the  leg  is  raised  across  the  opposite  knee,  and  the 
adductor  longus  is  rendered  distinct  when  the 
thigh  is  abducted  and  the  individual's  attempts 
to  adduct  the  limb  are  resisted.  Even  in  the 
obese  the  edge  of  this  muscle  can  be  felt  when 


512  THE    LOWER    EXTREMITY  [Chap. 

it  is  in  vigorous  action,  and  the  fingers 
follow  its  border  up  to  the  very  origin  of 
muscle,  just  below  the  pubic  spine. 

The  lymphatic  glands  in  this  region  can  some 
times  be  felt  beneath  the  skin,  especially  in  thir 
children.  The  femoral  ring  lies  behind  Poupart's 
ligament  1  inch  externally  to  the  pubic  spine  (Fig. 
72,  p.  352).  The  position  of  the  saphenous  open- 
ing is  sometimes  indicated  by  a  slight  depression 
in  the  integuments.  It  lies  just  below  Poupart's 
ligament,  and  its  centre  is  about  lj  inches  below 
and  external  to  the  pubic  spine.  In  thin  sub- 
jects the  long  saphenous  vein  can  be  often  made 
out,  passing  to  the  saphenous  opening. 

If  a  line  be  drawn  from  the  femoral  point 
(Fig.  72,  p.  352)#  to  the  tubercle  for  the  adductor 
magnus,  on  the  inner  condyle  of  the  femur,  when 
the  thigh  is#  slightly  flexed  and  abducted,  it  will 
correspond  in  the  upper  two-thirds  of  its  extent 
to  the  position  of  the  femoral  artery.  Just  below 
Poupart's  ligament  the  femoral  vein  lies  to  the 
inner  side  of  the  artery,  while  the  anterior  crural 
nerve  runs  about  J  of  an  inch  to  its  outer  side. 
The  profunda  femoris  arises  about  li  inches  below 
Poupart's  ligament,  and  the  internal  and  ex- 
ternal circumflex  vessels  come  off  about  2  inches 
below  that  structure. 

The  skin  over  Scarpa's  triangle  is,  unlike  that 
of  the  buttock,  comparatively  thin  and  fine.  The 
looseness  of  its  attachment,  also,  to  the  parts 
immediately  beneath,  permits  it  to  be  greatly 
stretched,  as  is  seen  in  cases  of  large  femoral 
hernise,  and  in  certain  inguinal  tumours  of  large 
size.  It  may  even  give  way  under  severe  traction, 
as  occurred  in  a  case  reported  by  Berne.  The 
patient  in  this  case  was  a  child  aged  11,  the  sub- 
ject of  hip  disease.  The^  thighs  were  flexed  upon 
the  abdomen,  and,  forcible  extension  being  ap- 
plied to  relieve  the  deformity,  the  skin  gave  way 
just  below  the  groin,  and  separated  to  the  extent 
of  some  2 \  inches.  Contracting  scars  in  the  region 
of  the  groin  may  produce  a  permanent  flexing  of 


XXII  SCARPA'S    TRIANGLE  513 

the  hip,  and  this  result  is  not  uncommon  after 
deep  and  severe  burns  in  this  neighbourhood.  It 
may  at  the  same  time  be  noted  that  horizontal 
wounds  about  the  groin  can  be  well  adjusted  by 
a  slight  flexion  of  the  thigh. 

Instances  are  recorded  where  a  supernumerary 
mammary  gland,  provided  with  a  proper  nipple, 
has  been  found  located  in  the  groin.  Jessieu 
relates  the  case  of  a  female  who  had  a  breast  so 
placed,  and  who  suckled  her  child  from  this 
part  (see  p.  213).  In  a  few  cases  the  testicle,  in- 
stead of  descending  into  the  scrotum,  has  escaped 
through  the  crural  canal,  and  made  its  appear- 
ance in  Scarpa's  triangle.  It  has  even  mounted 
up  over  Poupart's  ligament  after  the  manner  of  a 
femoral  hernia,  being  probably  urged  in  that 
direction  by  the  movements  of  the  limb.  m 

The  superficial  fascia  in  this  region  is  not 
very  dense,  and  has  little  or  no  influence  upon 
the  progress  of  a  superficial  abscess.  This  fact 
receives  extensive  illustration,  since  the  glands  in 
Scarpa's  triangle  frequently  suppurate,  and  yet 
the  pus  in  the  great  majority  of  cases  readily 
reaches  the  surface  in  spite  of  the^  circumstance 
that  the  denser  layer  of  the  superficial  fascia  (for 
in  this  region  it  is  divided  into  two  layers)  covers 
in  those  glands,  and  should  hinder  the  progress 
of  pus  towards  the  surface.  Although  the  sub- 
cutaneous fat  is  not  peculiarly  plentiful  in  this 
region,  yet  Scarpa's  triangle  is  a  favourite  spot 
for  lipomata. 

The  fascia  lata  completely  invests  the  limb, 
being,  so  far  as  the  front  of  the  thigh  is  con- 
cerned, attached  above  to  Poupart's  ligament,  to 
the  body  and  ramus  of  the  pubes,  and  the  ramus 
of  the  ischium.  Its  integrity  is  interrupted  only 
by  the  saphenous  opening.  This  fascia  exercises 
some  influence  upon  deep  abscesses  and  deep 
growths.  Thus  a  psoas  abscess  reaches  the  thigh 
by  following  the  substance  of  the  psoas  muscle, 
and  finds  itself,  when  it  arrives  at  Scarpa's  tri- 
angle, under  the  fascia  lata.     In  a  great  number 


. 


514  THE    LOWEE    EXTEEMITY  [Chap, 

of  cases  it  points  where  the  psoas  muscle  ends, 
but  in  other  and  less  frequent  instances  its  pro- 
gress is  decidedly  influenced  by  the  fascia  lata, 
and  it  moves  down  the  limb.  Thus  guided,  a 
psoas  abscess  has  pointed  low  down  in  the  thigh, 
and  even  at  the  knee,  and  Erichsen  reports  a  case 
where  such  an  abscess  (commencing,  as  it  did,  in 
the  dorsal  spine)  was  ultimately  opened  by  the 
side  of  the  tendo  Achillis. 

muscles.  —  The  ilio-psoas  muscle,  which  is 
stretched,  as  it  were,  over  the  front  of  the  hip- 
joint,  and  participates  in  many  of  the  movements 
of  that  joint,  is  peculiarly  liable  to  be  sprained  in 
violent  exercises.  Between  this  muscle  and  the  thin- 
nest part  of  the  hip  capsule  is  a  bursa^  which  not 
infrequently^  communicates  with  the  joint.  When 
chronically  inflamed,  this  bursa  may  form  a  large 
tumour  on  the  front  of  the  thigh  that  may,  ac- 
cording to  Nancrede,  attain  the  size  of  a  child's 
head.  To  relieve  this  bursa  from  pressure  when 
inflamed,  the  thigh  always  becomes  flexed,  and  a 
train  of  symptoms  is  produced  that  are  not  unlike 
those  of  hip  disease.  The  deep  origins  of  the  ilio- 
psoas lie  behind  the  caecum  and  kidney;  its  con- 
traction may  elicit  symptoms  when  these  organs 
are  diseased. 

The  sartorius  is  a  muscle  that,  from  its  length, 
peculiar  action,  etc.,  one  would  hardly  expect  to 
find  ruptured  from  violence,  yet  in  the  Musee 
Dupuytren  there  is  a  specimen  of  such  a  rupture 
about  the  middle  of  the  muscle  united  by  fibrous 
tissue.  The  adductor  muscles,  and  especially  the 
adductor  longus,  are  frequently  sprained,  or  even 
partially  ruptured,  during  horse  exercise,  the  grip 
of  the  saddle  being  for  the  most  part  maintained 
by  them.  "  Rider's  sprains,"  as  such  accidents 
are  called,  usually  involve  the  muscles  close  to 
their  pelvic  attachments.  Much  blood  is  often 
effused  when  the  fibres  are  ruptured,^  and  such 
effusion  may  become  so  dense  and  fibrinous  as  to 
form  a  mass  that  has  been  mistaken  for  a  detached 
piece  of  the  pubes  (Sir  Henry  Morris).    The  term 


XXI]  SCARPA'S    TRIANGLE  515 

"  rider's  bone  "  refers  to  an  ossification  of  the 
upper  tendon  of  the  adductor  longus  or  magnus, 
following  a  sprain  or  partial  rupture.  Cases 
are  reported  where  the  piece  of  bone  in  the  ten- 
don was  i  an  inch,  2  inches,  and  even  3  inches 
long. 

Blood-vessels.— The  femoral  artery  occupies 
so  superficial  a  position  in  Scarpa's  triangle  that 
it  is  not  infrequently  wounded.  The  vessel  also 
has  been  opened  up  by  cancerous  and  phagedenic 
ulcerations  of  this  part,  the  occurrence  leading  to 
fatal  haemorrhage.  Pressure  is  most  conveniently 
applied  to  the  artery  at  a  spot  immediately  below 
Poupart's  ligament,  and  should  be  directed  back- 
wards, so  as  to  compress  the  vessel  against  the 
pubes  and  adjacent  parts  of  the  hip  capsule. 
Lower  down,  compression  should  be  applied  in  a 
direction  backwards  and  outwards,  so  as  to  bring 
the  artery  against  the  shaft  of  the  femur,  which 
lies  at  some#  distance  to  its^  outer  side.  Pressure 
rudely  applied  by  a  tourniquet  may  cause  phle- 
bitis by  damaging  the  vein,  or  neuralgia  by  con- 
tusing the  anterior  crural  nerve. 

From  the  proximity  of  the  artery  and  vein, 
it  happens  that  arterio-venous  aneurysms  follow- 
ing wounds  have  been  met  with  in  this  situa- 
tion. Aneurysm  is  frequent  in  the  common 
femoral,  and  many  reasons  can  be  given  why  that 
vessel  should  be  attacked.  It  is  just  about  to 
bifurcate  into  two  large  trunks,  its  superficial 
position  exposes  it  to  injury,  it  is  greatly  influ- 
enced by  the  movements  of  the  hip,  and  its  coat 
may,  if  diseased,  be  damaged  by  those  movements, 
if  excessive. 

Phlebitis  of  the  femoral  vein  has  in  many  cases 
followed  contusion  of  the  vessel  in  its  upper  or 
more  superficial  part,  and  a  like  result  has  even 
followed  from  violent  flexion  of  the  thigh.  The 
long  saphenous  vein  is  often  varicose,  and  one 
form  of  the  varicosity^  is  said  to  depend  upon 
constriction  of  the  vein  by  an  unduly  narrow 
saphenous  opening.     That  varicose  veins  are,   in 


516  THE    LOWEE    EXTREMITY  [Chap. 

the  majority  of  cases,  of  congenital  origin  is  now 
very  generally  allowed. 

Nerves.— The  anterior  crural  lies  on  the  ilio- 
psoas muscle,  and  it  is  said  that  neuralgia,  and 
even  paralysis  of  the  nerve,  may  follow  upon  in- 
flammation of  that  muscle  and  upon  psoas  abscess. 
The  superficial  position  of  the  trunk  exposes  it  to 
injury.  The  genito=crural  nerve  (the  nerve  that 
supplies  the  cremaster  muscle)  gives  a  sensory  fila- 
ment to  the  integument  of  the  thigh  in  Scarpa's 
triangle.  Irritation  of  the  skin  over  the  seat  of 
this  nerve,  which  is  placed  just  to  the  outer  side 
of  the  femoral  artery,  will  cause,  in  children,  a 
sudden  retraction  of  the  testicle.  The  same  result 
is  often  seen  in  adults,  also,  on  more  severe  stimu- 
lation. In  this  manner  the  condition  of  the  second 
lumbar  segment  of  the  cord  may  be  tested. 

The  lymphatic  glands  in  this  region  are 
numerous,  and,  as  they  are  frequently  the  seat  of 
abscess,  it^  is  important  to  know  whence  they 
derive  their  afferent  vessels.  They  are  divided 
into  a  superficial  and  a  deep  set.  The  super- 
ficial set,  averaging  from  10  to  15  glands,  is  ar- 
ranged in  two  groups,  one  parallel  and  close  to 
Poupart's  ligament  (the  horizontal  series),  the 
other  parallel  and  close  to  the  long  saphenous  vein 
(the  vertical  series).  The  deep  set,  about  4  in 
number,  are  placed  along  the  femoral  vein,  and 
reach  the  crural  canal. 

The  inguinal  glands  receive  the  following  lym- 
phatics : — 

Superficial  vessels  of  lower  limb  =  vertical  set 
of  superficial  glands. 

Superficial  vessels  of  lower  half  of  abdomen  = 
middle  glands  of  horizontal  set. 

Superficial  vessels  from  outer  surface  of  but- 
tock =  external  glands  of  horizontal  set. 

From  inner  surface  of  buttock  =  internal 
glands  of  horizontal  set.  (A  few  of  these  vessels 
go  to  the  vertical  glands.) 

Superficial  vessels  from  external  genitals  — 
horizontal  glands,  *ome  few  going  to  vertical  set. 


XXIJ  SCARPA'S    TRIANGLE  517 

Superficial  vessels  of  perineum  and  anus  = 
vertical  set. 

Deep  lymphatics  of  lower  limb  =  deep  set  of 
glands. 

The  lymphatics  that  accompany  the  obturator, 
gluteal,  and  sciatic  arteries,  and  the  deep  vessels 
of  the  penis,  pass  to  the  pelvis  and  have  no  con- 
nexion with  the  inguinal  glands.  The  only  super- 
ficial lymphatics  of  the  lower  extremity  which  do 
not  pass  direct  to  the  inguinal  glands  are  those 
which  drain  the  outer  side  of  the  ankle  and  pos- 
terior aspect  of  the  leg.  The  vessels  from  these 
areas  accompany  the  short  saphenous  vein  and 
end  in  the  popliteal  glands;  the  efferent  vessels 
from  these  glands  pass  to  the  deep  inguinal  set. 

One  of  the  deep  glands  lies  in  the  crural  canal 
and  upon  the  septum  crurale.  Being  surrounded 
by  dense  structures,  it  is  apt  to  cause  great  dis- 
tress when  inflamed  and  great  pain  when  the  hip 
is  moved.  In  some  cases,  by  reflex  disturbance, 
it  has  produced  symptoms  akin  to  those  of 
strangulated  hernia.  Some  branches  of  the  an- 
terior crural  nerve  lie  over  the  inguinal  lymph 
glands,  and  Sir  B.  Brodie  reports  a  case  in  which 
these  branches  were  stretched  over  two  enlarged 
glands,  like  strings  of  a  violin  over  its  bridge, 
so  that  violent  pain  and  convulsive  movements 
were  set  up  in  the  limb. 

The  efferent  vessels  from  the  inguinal  glands 
pass  through  a  chain  of  lymphatic  glands  stretch- 
ing along  the  course  of  the  external  and  common 
iliac  vessels.  Three  of  these  glands  lie  imme- 
diately above  Poupart's  ligament.  The  efferent 
vessels  of  the  internal  iliac  group  of  glands,  into 
which  the  pelvic  lymphatics  drain,  join  the  chain 
along  the  common  iliac  vessels.  The  lumbar 
glands  receive  the  lymph  from  the  iliac  groups 
and  pass  it  on  by  the  right  and  left  lumbar  trunks 
to  the  receptaculum  chyli. 

Elephantiasis  Arabum  is  more  common  in  the 
lower  limb  than  in  any  other  part,  and  leads  to  an 
enormous   increase   in   the   size   of   the   extremity 


518  THE    LOWEE    EXTREMITY  [Chap. 

(Cochin  or  Barbadoes  leg).  Its  pathology  is  in^l 
timately  concerned  with  the  crural  lymphatics.  I 
The  lymphatics  are  obstructed  by  a  small  thread- 
worm, Filaria  sanguinis  hominis.  The  lymph-1 
vessels  and  lymph-spaces  in  the  connective  tissue] 
become  greatly  distended,  and  the  elements  of  the 
connective  tissue  hypertrophied. 

3.   The  Hip-Joint 

The  hip-joint  is  of  considerable  strength  (Fig.  | 
101),    not  only   on   account   of   the   shape   of   the  | 
articulating  bones,  which  permits  of  a  good  ball- 
and-socket  joint  being  formed,  but  also  because  of  j 
the  powerful  ligaments  that  connect  them  and  the  1 
muscular  bands  that  directly  support  the  capsule.  \ 
These   advantages,    however,    are   to   some   extent 
counterbalanced  by  the  immense  leverage  that  can 
be    brought   to    bear    upon    the    femur,    and    the 
numerous  strains  and  injuries  to  which  the  joint 
is  subjected,  as  the  sole  connecting  link  between 
the  trunk  and  the  lower  limb. 

The  acetabulum  is  divided  into  an  articular  . 
and  a  non-articular  part.  The  former  is  of 
horse-shoe  shape,  and  varies  from  1  inch  to  \  an 
inch  in  width.  The  bone  immediately  above  the 
articular  area  is  very  dense,  and  through  it  is 
transmitted  the  superincumbent  weight  of  the 
trunk.  The  non-articular  part  corresponds  to  the 
area  enclosed  by  the  horse-shoe,  and  is  made  up 
of  very  thin  bone.  It  is,  however,  rarely  frac- 
tured by  any  violence  that  may  drive  the  femur  up  I 
against  the  pelvic  bones,  since  no  ordinary  force 
can  bring  the  head  of  the  thigh-bone  in  contact 
with  this  segment  of  the  os  innominatum. 

Pelvic  abscesses  sometimes  make  their  way  into 
the  hip-joint  through  the  non-articular  part  of  the 
acetabulum,  and  an  abscess  in  the  hip-joint  may 
reach  the  pelvis  by  the  same  route.  But  both 
such  circumstances  are  rare.  In  some  cases  of  de- 
structive hip  disease  the  acetabulum  may  separate 
into  its  three  component  parts.  Up  to  the  age 
of  puberty  these  three  bones  are  separated  by  the 


XXI] 


THE    HIP-JOINT 


519 


Y-shaped  cartilage.  At  puberty  the  cartilage 
begins  to  ossify,  and  by  the  eighteenth  year  the 
acetabulum  is  one  continuous  mass  of  bone.     The 


Fig.  101.— Vertical  section  of  the  upper  third  of  the  thigh 
showing  the  structures  in  relationship  with  the  hip- 
joint.     {After  Br -aune.) 

Muscles.— 1  Psoas  ;  2  iliacus  ;  3,  gluteus  medius  ;  4,  gluteus  minimus  ; 
5,  obturator  internus  ;  6,  obturator  externus  ;  7,  ilio-psoas  ;  8,  pec- 
tineus  ;  9,  adductor  magnus  ;  10,  adductor  brevis ;  11,  gracilis  ; 
12,  adductor  longus ;  13,  vastus  internus  ;  14,  vastus  externus. 
a,  anterior  crural  nerve  ;  b,  external  iliac  artery  ;  c,  external  iliac 
vein  ;  d,  obturator  nerve ;  e,  obturator  artery  ;  /,  branches  of 
obturator  vessels  to  hip- joint ;  g,  internal  circumflex  vessels  ; 
h,  deep  femoral  vessels  ;  i,  branch  of  external  circumflex  :  j,  bursa 
over  great  trochanter  ;  k,  reflections  of  capsule  to  neck  of  femur  ; 
m,  asc.  ramus  of  pubes  ;  ?i,  peritoneum  ;  o,  iliac  fascia. 

breaking-up  of  the  acetabulum  by  disease,  there- 
fore, is  only  possible  before  that  year. 


520  THE    LOWER    EXTREMITY  [Chap. 

The  manner  in  which  the  various  movements  at 
the  hip  are  limited  may  be  briefly  expressed  as 
follows.  Flexion,  when  the  knee  is  bent,  is  limited 
by  the  contact  of  the  soft  parts  of  the  groin,  and 
by  some  part  of  the  ischio-femoral  ligament ;  when 
the  knee  is  extended  the  movement  is  limited  by 
the  hamstring  muscles.  Extension  is  limited  by 
the  ilio-femoral  or  Y  ligament.  Abduction,  by  the 
pubo-femoral  ligament.  Adduction  of  the  flexed 
limb  is  limited  by  the  ligamentum  teres  and  ischio- 
femoral ligament,  and  of  the  extended  limb  by 
the  outer  fibres  of  the  ilio-femoral  ligament  and 
upper  part  of  the  capsule.  Rotation  outwards  is 
resisted  by  the  ilio-femoral  ligament,  and  especi- 
ally by  its  inner  part,  during  extension,  and  by 
the  outer  limb  of  that  ligament  and  the  liga- 
mentum teres  during  flexion.  Rotation  inwards 
is  limited  during  extension  by  the  ilio-femoral 
ligament,  and  during  flexion  by  the  ischio-femoral 
ligament  and  inner  part  of  the  capsule.  #  The 
structures  which  take  the  chief  part  in  maintain- 
ing the  integrity  of  the  joint,  however,  are  not 
the  ligaments  but  the  strong  muscles  which  sur- 
round and  act  on  the  joint.  Atmospheric  pres- 
sure takes  no  part,  for  the  fat  at  the  transverse 
notch  is  readily  drawn  into  the  acetabulum  to 
make  good  any  space  vacated  by  the  femoral  head 
in  all  normal  movements  of  the  hip-joint. 

Hip-joint  disease.— Owing  to  its  deep  position 
and  its  thick  covering  of  soft  parts  (Fig.  101), 
this  articulation  is  able  to  escape,  to  a  great 
extent,  # those  severer  injuries  that  are  capable  of 
producing  acute^  inflammation  in  other  joints. 
Acute  synovitis  is  indeed  quite  rare  in  the  hip, 
and  the  ordinary  disease  or  the  part  is  of  a  dis- 
tinctly chronic  character.  It  follows,  also,  from 
the  deep  position  of  the  articulation  that  pus, 
when  it  is  formed  in  connexion  with  disease,  re- 
mains pent  up,  and  is  long  before  it  reaches  the 
surface.  Suppuration  in  this  region,  therefore, 
is  often  very  destructive.  When  effusion  takes 
place  into  the  joint,  the  swelling  incident  thereto 


XXI]  HIP-JOINT    DISEASE  521 

will  first  show  itself  in  those  parts  where  the  hip 
capsule  is  the  most  thin.  The  thinnest  parts  of  the 
capsule  are  in  front  and  behind;  in  front,  in 
the  triangular  interval  between  the  inner  edge 
of  the  Y  ligament  and  the  pubo-femoral  ligament, 
and  behind  at  the  posterior  and  lower  part  of  the 
capsule.  It  is  over  these  two  districts  that  the 
swelling  first  declares  itself  in  cases  of  effusion 
into  the  joint,  and  as  these  parts  are  readily  ac- 
cessible to  pressure,  it  follows  that  they^  corre- 
spond also  to  the  regions  where  tenderness  is  most 
marked  and  is  earliest  detected. 

In  chronic  hip  disease,  certain  false  positions 
are  assumed  by  the  affected  limb,  the  meaning  of 
which  it  is  important  to  appreciate.  These  posi- 
tions may  be  arranged  as  follows,  according,  as 
nearly  as  possible,  to  their  order  of  appearing  : 

(1)  The  thigh  is  flexed,  abducted,  and  a  little 
everted;  and  associated  with  this  there  is  (2) 
apparent  lengthening  of  the  limb  and  (3)  lordosis 
of  the  spine;  (4)  the  thigh  is  adducted  and  in- 
verted, and  incident  to  this  there  is  (5)  apparent 
shortening  of  the  limb;  (6)  there  is  real  shorten- 
ing of  the  limb. 

(1).  The  first  position  is  simply  the  posture  of 
greatest  ease.  It  depends  mainly  upon  the  effu: 
sion  into  the  joint.  If  fluid  be  forcibly  injected 
into  a  hip-joint  the  thigh  becomes  flexed,  abducted, 
and  a  little  everted.  In  other  words,  the  articula- 
tion holds  the  most  fluid  when  the  limb  is  in  this 
position,  and  the  patient  places  it  there  to  relieve 
pain  by  reducing  the^  tension  within  the  capsule 
to  a  minimum.  Flexion  is  the  most  marked  fea- 
ture in  this  position.  Its  effect  is  pronounced. 
It  relaxes  the  main  part  of  the  Y  ligament,  which, 
when  the  limb  is  straight,  is  drawn  as^  an  unyield- 
ing band  across  the  front  of  the  joint.  Abduc- 
tion relaxes  the  outer  limb  of  this  ligament  and 
the  upper  part  of  the  capsule.  Eversion  slightly 
relaxes  the  inner  limb  of  the  Y  ligament  and  the 
ischio-femoral  ligament.  The  latter  movement  is 
the  least  marked,  since  eversion,  even  in  the  flexed 


522 


THE    LOWER    EXTREMITY 


[Chap. 


position  of  the  joint,  is  resisted  by  the  outer  part 
of  the  Y  Jigamenk  Any  but  a  moderate  degree  of 
abduction  would  be  limited  by  the  pubo-femoral 
ligament,  especially  as  that  band  is  rendered  most 
tense  when  abduction  is  combined  with  flexion 
and  rotation  outwards.     The  attachments  of  the 

psoas  muscle  are  ap- 
proximated and  its 
pressure  over  the 
joint  relaxed. 

(2).  The  apparent 
lengthening  is  due  to 
the  tilting  down  of 
the  pelvis  on  the  dis- 
eased side,  and  is  the 
result  of  the  pa- 
tient's attempts  to 
overcome  the  effects 
of  the  position  just 
described.  The  limb 
is  shortened  by 
flexion  and  abduc- 
tion, and  to  bring 
the  foot  again  to  the 
ground  and  to  re- 
store the  natural 
parallelism  of  the 
limbs,  the  pelvis  has 
to  be  tilted  down 
on  the  affected  side. 
Thus  an  apparent 
lengthening  is  pro- 
duced, which  is  seen 
when  the  patient  lies 
upon  a  bed  and  the  abduction  is  made  to  dis- 
appear. Real  lengthening  of  the  limb  can  scarcely 
be  produced  by  the  effusion  into  the  joint.  By 
forcible  injection  into  the  joint  Braune  could 
only  separate  the  articulating  surfaces  about  Jth 
of  an  inch. 

(3).  The  lordosis,  or  curving  forwards,  of  the 
spine  occurs  in  the  _  dorso-lumbar  region.  It 
depends  upon  the  flexion  of  the  limb,  and  is  the 


a  a 

Fig.     102. — Diagram     to     show 

the      mode     of    production    of 

lordosis    in    hip    disease. 

A,  Femur  flexed  at  hip,  pelvis  (repre- 
sented by  the  dotted  line)  straight, 
and  spine  normal.  B,  The  flexion 
concealed  or  overcome  by  lordosis 
of  the  spine ;  the  pelvis  rendered 
oblique. 


XXII  HIP-JOINT    DISEASE  523 

result  of  an  attempt  to  conceal  that  false  position, 
or  at  least  to  minimize  its  inconveniences  (Fig. 
102).  When  the  thigh  is  flexed  at  the  hip  by 
disease,  the  lower  limb  can  be  made  to  appear 
straight  by  simply  bending  the  spine  forwards  in 
the  dorso-lumbar  region  without  effecting  the  least 
movement  at  the  disordered  joint.  Indeed,  the 
movement  proper  to  the  hip  is  in  this  case  trans- 
ferred to  the  spine.  A  patient  with  a  flexed  hip 
as  the  result  of  disease  can  lie  on  his  back  in  bed, 
with  both  limbs  apparently  perfectly  straight,  he 
having  concealed  the  flexion,  as  it  were,  by  pro- 
ducing a  lordosis  of  the  spine.  If  the  lordosis  be 
corrected  and  the  spine  be  made  straight  again, 
then  the  flexion  of  the  hip  reappears,  although 
all  the  time  the  hip-joint  has  been  absolutely 
rigid.  This  lordosis  generally  appears  a  little 
late  in  the  disease,  and  after  the  limb  has  become 
more  or  less  fixed  in  the  false  position  by  con- 
traction of  the  surrounding  muscles. 

(4).  Sooner  or  later,  in  hip  disease,  the  thigh 
becomes  adducted  and  inverted,  while  it  still 
remains  flexed.  The  head  of  the  femur  then  rests 
on  the  upper  and  posterior  part  of  the  acetabu- 
lum, quite  half  of  it  being  outside  the  socket. 
This  position  has  been  variously  accounted  for. 
According  to  one  theory,  it  is  due  to  softening  and 
yielding  of  some  parts  of  the  inflamed  capsule. 
It  is  more  probable  that  this  false  position,  and 
especially  the  adduction,  depends  upon  muscular 
action.  The  muscles  about  the  joint  are  in  a 
state  of  irritability.  They  are  contracted  by  a 
reflex  action  that  starts  from  the  inflamed  articu- 
lation, and  since  the  adductor  muscles  are  sup- 
plied almost  solely  by  the  obturator  nerve,  it  is 
not  unreasonable  to  expect  them  to  be  especially 
disturbed  if  the  large  share  that  the  obturator 
nerve  takes  in  the  supply  of  the  hip  be  borne 
in  mind.  The  whole  matter,  however,  requires 
further  investigation. 

(5).  Apparent  shortening  of  the  limb  is  due  to 
tilting  up  of  the  pelvis  on  the  diseased  side,  and 


524 


THE    LOWER    EXTREMITY 


LChap. 


bears  the  same  relation  to  adduction  that  ap- 
parent lengthening  bears  to  abduction.  To  over- 
come the  adduction,  and  to  restore  the  natural 
parallelism  of  the  limbs,  the  patient  tilts  up  one 
side  of  his  pelvis  (Fig.  103).  It  thus  happens  that 
a  patient  with  his  femur  flexed  and  adducted  Jby 
disease  may  lie  in  bed  with  both  limbs  quite 
straight  and  parallel,  but  with  one  limb  obviously 


C    A. 


B 

ABC 

Fig.   103. — A,   Parts  in  normal   position.      B,   The  adduc- 
tion   corrected    by    tilting    up    the    pelvis.       G,     Femur 
adducted 

AC,  Line  of  pelvis  ;  AB,  limb  on  diseased  side  ;  CD,  limb  on  sound 
side ;  E,  the  spine.  It  will  be  found  that  in  Figs.  B  and  C  the 
angle  at  A  is  the  same  in  the  two  cases. 


shorter  than  the  other.  ,  The  flexion  in  such  a  case 
is  concealed  by  lordosis,  and  the  adduction  by 
the  tilting  of  the  pelvis.  In  some  cases  of  simul- 
taneous disease  in  both  hip-joints  that  has  been 
indifferently  treated,  both  thighs  may  remain 
adducted.  The  limbs  are  unable,  of  course,  to 
remedy  their  position  by  the  usual  means,  when 
the  disease^  is  double,  and  consequently  one  limb 
is  crossed  in  front  of  the  other,  and  the  peculiar 


XXI]  HIP-JOINT    DISEASE  525 

mode  of  locomotion  known  as  "  cross-legged  pro- 
gression ;;  is  produced. 

(6).  The  real  shortening  depends  upon  destruc- 
tive changes  in  the  head  of  the  bone,  or  upon 
dislocation  of  the  partly  disintegrated  head  on  to 
the  dorsum  ilii,  through  yielding  of  the  softened 
capsule  and  the  crumbling  away  of  the  upper  and 
posterior  margin  of  the  acetabulum. 

When^  hip  disease  commences  in  the  bone  it 
usually  involves  the  epiphyseal  line  that  unites 
the  head  of  the  femur  to  the  neck.  This  line  is 
wholly  within  the  joint,  and  the  epiphysis  that 
forms  the  head  unites  with  the  rest  of  the  bone 
about  the  eighteenth  or  nineteenth  year  (Fig-.  101). 

It  is  well  known  that  patients  with  hip  disease 
often  complain  of  pain  in  the  knee.  This  referred 
pain  may  be  so  marked  as  entirely  to  withdraw 
attention  from  the  true  seat  of  disease.  Thus  I 
once  had  a  child  sent  to  the  hospital  with  a  sound 
knee  carefully  secured  in  splints,  but  without  any 
appliance  to  the  hip,  which  was  the  seat  of  a 
somewhat  active  inflammation.  This  referred 
pain  is  easy  to  understand,  since  the  two  joints 
are  supplied  from  the  same  segments  of  the  spinal 
cord.  In  the  hip,  branches  from  (1)  the  anterior 
crural  enter  at  the  front  of  the  capsule ;  (2) 
branches  from  the  obturator  at  the  lower  and 
inner  part  of  the  capsule ;  and  (3)  branches  from 
the  sacral  plexus  and  sciatic  nerve  at  the  pos- 
terior part  of  the  joint.  In  the  knee,  branches 
from  (1)  the  anterior  crural  (nerves  to  vasti) 
enter  at  the  front  of  the  capsule ;  (2)  branches 
from  the  obturator  at  the  posterior  part  of  the 
capsule ;  and  (3)  branches  from  the  internal  and 
external  popliteal  divisions  of  the  great  sciatic 
nerve  at  the  lateral  and  hinder  aspects  of  the 
joint. 

Pain,  therefore,  in  the  front  of  the  knee,  on 
one  or  both  sides  of  the  patella,  has  probably  been 
referred  along  the  anterior  crural  curve,  and 
pain  at  the  back  of  the  joint  along  the  obturator 
or  sciatic  nerves. 


526  THE    LOWER    EXTREMITY  LChap. 

In  hysterical  individuals  joint  disease  may  be 
imitated  by  certain  local  nervous  phenomena,  the 
articulation  itself  being  quite  free  from  struc- 
tural change.  This  affection  most  commonly 
shows  itself  in  the  hip  or  knee,  and  the  "  hys- 
terical hip,"  or  "hysterical  knee,"  takes  a  promi- 
nent place  in  the  symptomatology  of  hysteria. 
It  is  not  quite  easy  to  understand  why  these  two 
large  joints  should  be  so  frequently  selected  for 
the  mimicry  of  disease.  Hilton  has  endeavoured 
to  explain  the  fact  upon  anatomical  grounds, 
having  reference  to  the  nerve  supply  of  these 
joints  in  relation  to  the  nerve  supply  of  the 
uterus.  The  uterus  is  mainly  supplied  by  an 
offshoot  from  the  hypogastric  plexus,  and  by  the 
3rd  and  4th  sacral  nerves.  Now,  the  hypogas- 
tric plexus  contains  filaments  derived  from  the 
lower  lumbar  nerves;  and  from  the  same  trunks 
two  nerves  to  the  hip  and  knee  (the  anterior 
crural  and  obturator)  are  in  great  part  derived. 
The  great  sciatic  also  contains  a  large  portion 
of  the  3rd  sacral  nerve.  The  common  origin  of 
the  joint  and  uterine  nerves  forms  the  basis 
of  Hilton's  explanation  of  the  relative  frequency 
of  hysterical  disease  in  the  large  articulations  of 
the  lower  limb.  The  explanation,  however,  is  un- 
satisfactory, since  the  uterus  receives  many  of  its 
nerves  from  the  ovarian  plexus,  and  the^  theory  is 
founded  upon  the  unwarranted  supposition  that 
all  hysterical  disorders  are  associated  with  some 
affection  of  the  uterus  or  its  appendages.  More 
recently  Head  has  revived  a  modified  form  of 
Hilton's  theory.  He  explains  the  connexion  not 
through  an  anatomical  association  of  nerves,  but 
through  an  association  of  the  centres  from  which 
nerves  arise  in  the  spinal  cord.  The  spipal  seg- 
ments from  which  the  obturator  nerve  arises,  the 
second,  third,  and  fourth,  contain  no  visceral 
nerves,  and,  therefore,  cannot  be  associated  with 
visceral  conditions.  On  the  other  hand,  the 
sacral  segments  from  which  the  great  sciatic  nerve 
arises  are  those  which  supply  the  pelvic  viscera. 


XXI]  FKACTURES    OF    THE    FEMUR  527 

Fractures  of  the  tipper  end  of  the  femur 

may  be  divided  into  (1)  fractures  of  the  neck 
wholly  within  the  capsule;  (2)  fractures  of  the 
base  of  the  neck  not  wholly  within  the  capsule; 
(3)  fractures  of  the  base  of  the  neck  involving  the 
great  trochanter;  (4)  separations  of  epiphyses.  It 
can  be  scarcely  possible,  apart  from  gunshot  in- 
juries, to  fracture  the  neck  of  the  femur  by  direct 
violence,  owing  to  the  depth  at  which  the  bone 
is  placed,  and  the  manner  in  which  it  is  protected 
by  the  surrounding  muscles.  The  violence,  there- 
fore, that  causes  the  lesion  is  nearly  always  sup- 
plied indirectly  to  the  bone,  as  by  a  fall  upon  the 
feet  or  great  trochanter,  or  by  a  sudden  wrench 
of  the  lower  limb. 

(1).  The  true  intracapsular  fracture  may  involve 
any  part  of  the  cervix  within  the  joint,  but  is 
most  usually  found  near  the  line  of  junction  of 
the  head  with  the  neck.  This  fracture  is  most 
common  in  the  old,  in  whom  it  may  be  produced 
by  very  slight  degrees  of  violence.  The  liability 
of  the#  aged  to  this  lesion  is  explained  upon  the 
following  grounds  :  The  angle  between  the  neck 
and  shaft  of  the  femur,  which  is  about  130°  in 
a  child,  tends  to  diminish  as  age  advances,  so 
that  in  the  old  it  is  commonly  about  125°.  In 
certain  aged  subjects,  as  a  result  probably  of  gross 
degenerative  changes,  this  angle  may  be  reduced 
to  a  right  angle.  This  diminution  of  the  angle 
certainly  increases  the  risk  of  fracture  of  the 
neck  of  the  bone.  There  is  often,  besides,  in  ad- 
vanced life,  much  fatty  degeneration  of  the  can- 
cellous tissue  of  the  cervix  with  thinning  of  the 
compact  layer.  Dr.  Merkel  (Amer.  Journ.  Med. 
Sci.,  1874)  also  asserts  that  in  old  persons  there  is 
an  absorption  of  that  process  of  the  cortical  sub- 
stance which  runs  on  the  anterior  part  of  the  neck 
between  the  lesser  trochanter  and  the  under  part 
of  the  head.  This  process  he  calls  the  "calcar 
femorale,;;  and  maintains  that  it  occupies  the 
situation  at  which  the  greatest  pressure  falls  when 
the  body  is  erect  (Fig.  104).  These  fractures  are  but 


528  THE    LOWER    EXTREMITY  TChap. 

rarely  impacted;  but  when  impacted,  the  lower 
fragment,  represented  by  the  relatively  small  and 
compact  neck,  is  driven  into  the  larger  and  more 
cancellous  fragment  made  up  of  the  head  of  the 
bone.  The  fracture  may  be  subperiosteal,  or  the 
fragments  may  be  held  together  by  the  reflected 
portion  of  the  capsule.  These  reflected  fibres  pass 
along  the  neck  of  the  bone  from  the  attachment 
of  the  capsule  at  the  femur  to  a  point  on  the 
cervix  much  nearer  to  the  head.  "  These  reflected 
fibres  occur  at  three  places,  one  corresponding  in 
position  to  the  middle  of  the  ilio-femoral  liga- 
ment, another  to  the  pectineo-femoral,  and  the 
third  on  the  upper  and  back  part  of  the  neck  ,? 
(Sir  Henry  Morris).  Fractures  of  this  part  very 
rarely  indeed  unite  by  bone.  Blood  is  brought  to 
the  head  of  the  femur  by  vessels  in  the  neck  of  the 
bone,  in  the  reflected  parts  of  the  capsule,  and  in 
the  ligamentum  teres.  When  the  first  two  sources 
of  blood  supply  are  cut  off  by  the  fracture,  the 
third  does  not  appear  to  be  sufficient  to  allow  of 
great  reparative  changes  taking  place  in  the 
upper  fragment.  The  fractures  that  heal  by  bone 
are  probably  either  impacted,  or  subperiosteal,  or 
not  wholly  intracapsular. 

(2).  In  connexion  with  fractures  at  the  base 
of  the  neck,  it  must  be  remembered  that  a  wholly 
extracapsular  fracture  of  the  neck  of  the  femur 
is  an  anatomical  impossibility.  If  the  fracture  is 
wholly  without  the  capsule,  then  it  must  involve  a 
part  of  the  femoral  shaft,  and  cannot  be  entirely 
through  the  cervix.  In  the  front  of  the  bone  the 
capsule  is  attached  to  the  femur  along  the  inter- 
trochanteric  line,  and  strictly  follows  the  line  of 
junction  between  the  cervix  and  the  shaft.  Be- 
hind, the  capsule  is  inserted  into  the  neck  about 
\  an  inch  above  the  posterior  intertrochanteric 
line.  It  is  therefore  possible  for  a  fracture  of  the 
neck  to  be  extracapsular  behind,  but  not  in  front, 
and  many  of  these  lesions  at  the  base  of  the  neck 
have  this  relation  to  the  capsule.  The  Y  liga- 
ment is  so  thick,  being  in  one  place  about  \  of  an 


XXI]  FRACTURES    OF    THE   FEMUR  529 

inch  in  thickness,  that  a  fracture  involving  the 
base  of  the  cervix  may  run  between  its  fibres  at 
their  attachment,  and  be  neither  extra-  nor  intra- 
capsular. When  fractures  at  the  junction  of  the 
neck  and  shaft  are  impacted,  the  upper  fragment, 
represented  by  the  compact  and  relatively  small 
cervix,  is  driven  into  the  cancellous  tissue  about 
the  great  trochanter  and  upper  end  of  the  shaft 
(Fig.    104).      As    a    result   of   this   impaction   the 


Ant.  Dense  Layer 


Calcar  Femorale 


Ant.  Fragment  of 
Great  Trochanter 


Fig.  104. — The  calcar  femorale  and  its  relationship  to 
impacted  fractures  of  the  neck  of  the  femur.  {Ralph 
Thompson. ) 

trochanter  may  be  split  up,  and  the  bones  may 
become  free  again  through  the  extent  of  this 
splintering.  The  impacted  end  of  the  cervical 
fragment  is  shaped  like  a  chisel;  the  qalcar 
femorale  forming  its  cutting  edge  (R.  Thompson) 
With  regard  to  the  symptoms  of  a  fracture 
of  the  neck  of  the  femur,  the  following  may 
be  noticed  :  (a)  The  swelling  often  observed  in 
the  front  of  the  limb,  just  below  Poupart's  liga- 
ment, is  due  either  to  effusion  of  blood  into  the 
joint  or  to   projection  of  the  fragments  against 


530  THE    LOWER    EXTREMITY  [Chap. 

the  front  of  the  capsule;  (6)  the  shortening  is 
brought  about  by  the  glutei,  the  hamstrings,  the 
tensor  vaginae  femoris,  the  rectus,  sartorius,  and 
ilio-psoas,  the  adductors,  gracilis,  and  pectineus; 
(c)  the  eversion,  or  rotation  outwards  of  the  limb, 
is  mainly  due  to  two  causes  :  (i)  the  weight  of 
the  limb,  which  causes  it  to  roll  outwards,  as  is 
seen  in  persons  insensible  or  asleep,  the  line  of 
gravity  passing  through  the  outer  part  of  the 
thigh ;  (ii)  the  fact  that  the  compact  tissue  on  the 
posterior  aspect  of  the  neck  is  much  more  fragile 
than  that  on  the  anterior  aspect.  Thus  the  cervix 
is  often  more  extensively  fractured  behind  than  in 
front,  or  the  fracture  may  be  impacted  behind 
but  not  in  front,  and  in  either  case  the  limb  will 
tend  to  become  everted.  As  a  third  cause  may 
be  mentioned  the  action  of  the  ilio-psoas,  the 
adductor  and  pectineus  muscles,  and  of  the  small 
rotator  muscles,  all  of  which  will  tend  to  roll  the 
femur  outwards. 

(3).  Fracture  of  the  base  of  the  neck,  involving 
the  great  trochanter.  In  this  lesion  the  head, 
the  cervix,  and  a  part  of  the  great  trochanter 
are  separated  from  the  shaft  and  the  rest  of  the 
trochanter. 

(4).  Separation  of  epiphyses.  There  are  three 
epiphyses  in  the  upper  end  of  the  femur ;  one  for 
the  head,  which  unites  between  18  and  19  years 
of  age;  one  for  the  lesser  trochanter,  which  unites 
about  17;  and  one  for  the  greater  trochanter, 
which  unites  about  18.  #  The  neck  is  formed  by 
an  extension  of  ossification  from  the  shaft  (Fig. 
105).  The  epiphysis  for  the  head  is  secured 
against  separation  by  being  shaped  like  a  cap, 
by  its  epiphyseal  line  being  arranged  trans- 
versely to  the  axis  of  the  femur,  and  also  by  its 
intracapsular  position.  The  epiphysis,  t  however, 
is  subject  to  a  peculiar  form  of  dislocation  which 
gives  rise  to  the  condition  of  coxa  vara.  The 
epiphysis  gradually  tilts  downwards  so  that  the 
neck  of  the  femur  appears  to  sink  under  the 
weight  of  the  body,  coming  to  form  an  angle  of 


XXI]  DISLOCATIONS    OF    THE    HIP  531 

90°  or  less  with  the  shaft  of  the  femur.  It  occurs 
in  adolescents.  Owing  to  the  prominence  of  the 
trochanter  and  shortening  of  the  limb  i  which 
necessarily  result,  the  condition  may  be  mistaken 
for  a  fracture  of  the  neck  of  the  femur  or  a  con- 
genital dislocation  of  the  hip-joint.  The  great 
trochanter  may  be  separated.  The  epiphyseal  lines 
of  the  head  and  great  trochanter  are  continuous 
until  the  neck  is  ossified  (see  Fig.   105). 

Dislocations  of  Ihe  hip. — These  injuries  are 
comparatively    rare,    on    account    of    the    great 


ABC  D 

Fig.  105. — Illustrating    the    ossification    of   the  upper  ex- 
tremity of  the  femur  and  the  condition  of  coxa  vara. 

{After  Elmslie.) 

A,  The  upper  extremity  at  birth. 

B,  „  „  at  2nd  year. 

C,  „  „  at  4th  year. 

D,  „  „  of  a  femur  from 
a  subject  of  coxa  vara. 

strength  of  the  articulation,  and  when  they  occur 
in  a  healthy  joint  are  always  the  result  of  a  con- 
siderable degree  of  violence.  A  dislocation  of  the 
hip  may  be  congenital,  or  may  be  spontaneously 
produced  by  muscular  efforts,  as  shown  in  a  few 
rare  cases,  or  may  be  the  result  of  disease  of  the 
articulation.  Congenital  dislocation  of  the  hip~ 
joint  is  due  in  most  instances  to  a  failure  in  the 
development  of  the  acetabulum.  In  such  cases 
the  acetabulum  retains  the  shallow  character  seen 
during  the  second  month  of  foetal  life.  The  out- 
growth of  the  acetabular  rim  fails,  especially  in 
the   iliac   part.      The   acetabular   cavity   becomes 


532  THE    LOWEE    EXTREMITY  [Chap. 

filled  up  by  the  duplication  of  the  capsule,  which 
is  unduly  lax  (Fig.  106).  The  round  ligament  may 
be  intact  or  deficient.  The  head  of  the  femur 
becomes  flat  and  the  neck  short,  and  the  bone 
slips  backwards  on  the  dorsum  ilii  when  the  child 
learns  to  walk.  The  weight  of  the  body  is  sup- 
ported by  the  muscles  and  ligaments  round  the 
hip-joint.  If  replaced  the  head  again  slirjs  from 
the  shallow  cavity.  In  time  osteophytic  out- 
growths from  the  ilium  lead  to  the  formation  of 
a  new  cavity.  The  deformity  is  evidently  corre- 
lated with  the  development  of  the  female  sexual 


CwutealMuscles 


Qrt  TR0C/1A/1TEB 


Fig.  106. — Congenital  dislocation  of  the  hip. 

From  a  specimen  presented  to  the  London  Hospital  Medical  College 
Museum  by  Mr.  Openshaw.  It  was  obtained  from  a  child  aged 
4  years. 

organs,  for  it  occurs  nearly  nine  times  more 
frequently  in  female  than  in  male  children 
(Fairbanks). 

In  dislocations  due  to  violence  the  head  of  the 
bone  may  be  found  displaced  in  four  directions, 
producing  the  four  regular  dislocations  of  the 
hip.  In  two  the  head  of  the  femur  is  posterior 
to  a  line  drawn  vertically  through  the  acetabulum, 
and  in  the  other  two  it  is  found  anterior  to  that 
line. 

(1)  Backwards  and  upwards.  Head  rests  upon 
ilium,  just  above  and  behind  acetabulum.  The 
"dislocation  upon  the  dorsum  ilii.n  (2)  Back- 
wards.    Head  rests  upon  ischium,  and,  as  a  rule; 


XXII  DISLOCATIONS    OF    THE    HIP  533 

about  on  a  level  with  the  ischial  spine.  The  "  dis- 
location into  the  sciatic  notch."  (3)  Forwards 
and  downwards.  Head  rests  on  thyroid  foramen. 
The  "  obturator  or  thyroid  dislocation"  (4)  For- 
wards and  upwards.  Head  rests  upon  the  body 
of  the  pubes,  close  to  its  junction  with  the  ilium. 
The  "  dislocation  upon  the  pubes" 

The  above  arrangement  represents  also  the 
order  of  frequency  of  these  luxations,  No.  1  being 
the  most  common  dislocation  of  this  part,  and 
No.  4  the  most  rare. 

General  facts.— In  all  these  dislocations^  the 
hip,  (a)  the  luxation  occurs  when  the  limb  is 
in  the  position  of  abduction ;  (b)  the  rent  in  the 
capsule  is  always  at  its  posterior  and  lower  part; 
(c)  the  head  of  the  bone  always  passes  at  first  more 
or  less  directly  downwards ;  (d)  the  Y  ligament  is 
untorn,  while  the  ligamentum  teres  is  ruptured. 

(a)  It  is  maintained  that  in  all  luxations  at 
the  hip,  the  pelvis  and  femur  are  in  the  mutual 
position  of  abduction  of  the  latter  at  the  time  of 
the  accident.  The  direction  of  the  neck  of  the 
femur  and  of  the  acetabulum,  and  the  position  of 
the  cotyloid  notch,  all  favour  dislocation  in  the 
abducted  posture.  The  lower  and  inner  part  of 
the  acetabulum  is  very  shallow,  and  the  lower  and 
posterior  part  of  the  capsule  is  very  thin.  In 
abduction,  the  head  of  the  bone  is  brought  to  the 
shallow  part  of  the  acetabulum;  it  moves  more 
than  half  out  of  that  cavity ;  it  is  supported 
only  by  the  thin  weak  part  of  the  capsule,  and  its 
further  movement  in  the  direction  of  abduction 
is  limited  only  by  the  pubo-femoral  ligament,  a 
somewhat  ^  feeble  band.  In  abduction  the  round 
ligament  is  slack,  and  in  abcjuction  with  flexion 
both  the  Y  ligament  and  the  ischio-femoral  liga- 
ments are  also  relaxed.  In  the  position  of  abduc- 
tion, therefore,  no  great  degree  of  force  may  be 
required  to  thrust  the  head  of  the  bone  through 
the  lower  and  posterior  part  of  the  capsule  and 
displace  it  downwards. 

(b)  The  above  being  allowed,  it  will  be  under- 


534  THE    LOWER    EXTREMITY  [Chap. 

stood  that  the  rent  in  the  capsule  is  always  at  its 
posterior  and  lower  parts.  "  Generally  the  rup- 
ture is  jagged  and  irregular,  but  will  be  found 
to  extend  more  or  less  directly  from  near  the 
shallow  rim  of  the  acetabulum,  across  the  thin 
portion  of  the  capsule  to  the  femur  near  the  small 
trochanter,  and  then  to  run  along  the  back  of  the 
ligament  close  to  its  attachment  to  the  neck  of 
the  bone"    (Sir  Henry  Morris). 

(c)  If  the  position  of  the  limb  at  the  time  of 
the  accident  be  considered,  it  will  be  seen  that  the 
femur  will  in  every  case  be  displaced  downwards. 
There  is,  indeed,  but  one  primary  dislocation  of 
the  hip — a  luxation  downwards.  The  four  forms 
given  above  are  all  secondary,  the  bone  having  in 
each  instance  first  passed  downwards  before  it 
moved  to  any  of  the  positions  indicated.  This 
point  has  been  ably  demonstrated  by  Sir  Henry 
Morris,  whose  account  of  the  anatomy  of  hip  dis- 
locations is  most  valuable.  The  head  having  left 
the  acetabulum,  its  ultimate  destination  will  de- 
pend upon  the  character  of  the  dislocating  force. 
"  If  the  limb  be  flexed  on  the  pelvis,  and  rotated 
inwards,  or  the  pelvis  be  correspondingly  moved 
on  the  thigh  at  the  moment  of  displacement,  the 
head  of  the  femur  will  take  a  backward  course 
and  rest  on  the  dorsum  ilii  or  some  part  of  the 
ischium.  On  the  other  hand,  extension  and  out- 
ward rotation  will  cause  the  head  of  the  bone  to 
travel  upwards  and  forwards,  and  what  is  called 
a  dislocation  on  to  the  pubis  will  occur.  ^  .  .  . 
If  the  dislocation  is  neither  accompanied  nor 
followed  by  rotation  or  fixed  flexion  or  extension, 
the  head  of  the  femur  will  remain  below  the 
acetabulum,  and  will  occupy  the  foramen  ovale 
if  it  takes  a  slightly  forward  direction  in  its 
descent, .  or  some  position  near  the  tuberosity  of 
the  ischium  if  it  leaves  its  socket  in  a  backward 
and   downward   direction"    (Morris). 

(d)  The  Y  ligament  is  never  torn  in  any  regu- 
lar dislocation.  It  is  saved  by  its  great  density 
and  the   circumstance  that  it  is   probably   more 


XXI] 


DISLOCATIONS    OF    THE    HIF 


535 


or  less  relaxed  at  the  time  of  the  luxation.  The 
method  of  reducing  these  dislocations  by  mani- 
pulation depends  for  its  success  mainly  upon 
the  integrity  of  the  Y  ligament,  which  acts  as 
the  fulcrum  to  a  lever  of  which  the  shaft  of  the 
femur  is  the  long  arm  and  the  neck  the  short. 
In  the  backward  luxations  the  head  is  behind  the 
Y  ligament,  and 
in  the  forward 
displacements  in 
front  of  it. 

The  anatomy 
of  each  form  of 
hip  dislocation.— 
Nos.  1  and  2  : 
The  dislo  ca- 
tions backwards 
(Fig.  107).— The 
femoral  head, 
having  been  dis- 
placed in  the 
way  indicated,  is 
carried  towards 
the  dorsum  or 
sciatic  notch  by 
the  glutei,  ham- 
string, and  ad- 
ductor muscles.  Fig.  107.- Dislocation  upon  the 
The  bone  having  dorsum  ilii.     [Bigelow.) 

taken    a   general 

direction  backwards,  the  height  to  which  it  ascends 
depends  mainly  upon  the  nature  of  the  dislo- 
cating force,  and  also  upon  the  extent  of  the 
rupture  in  the  capsule  v  and  the  laceration  of 
the  obturator  internus  tendon  and  other  small 
external  rotators.  The  dorsal  dislocation  is, 
therefore,  a  more  advanced  grade  of  the  sciatic. 
The  more  extreme  the  flexion  and  inward  rota- 
tion at  the  time  of  the  accident,  the  more  likely 
is  the  dislocation  to  be  sciatic.  More  moderate 
flexion  and  inward  rotation  will  produce  a  luxa- 
tion  upon  the   dorsum.     In   the   dorsal   luxation 


536 


THE    LOWER    EXTREMITY 


[Chap. 


the  head  is  above  the  obturator  interims  tendon, 
while  in  the  sciatic  form  it  is  below  it  (Bigelow). 
Morris  has  been  able  to  find  but  one  case  of  direct 
dislocation  of  the  femur  backwards  on  to  the 
ischium.  In  every  instance  it  passes  first  in  a 
downward  direction,  and  then  backwards. 

Bigelow  states  that  there  is  no  evidence  to  show 
that  the  head  of  the  femur  has  even  been  actually 

displaced    into    the 
sciatic  notch. 

In  these  back- 
ward dislocations 
the  ilio-psoas  muscle 
is  greatly  stretched. 
The  quadratus  fe- 
moris,  the  obtura- 
tors, the  gemelli, 
and  the  pyriformis 
are  more  or  less 
lacerated.  The  pec- 
tineus  is  often  torn, 
and  the  glutei  mus- 
cles even  may  be 
ruptured  in  part. 
The  great  sciatic 
nerve  may  be  com- 
pressed between  the 
femoral  neck  and 
the  rotator  muscles, 
or  between  the  head 
of  the  bone  and 
the  tuber  ischii.  In 
both  of  the  backward  luxations  there  is  shorten- 
ing due  to  the  circumstance  that  the  line  between 
the  anterior  superior  spine  and  the  femoral 
condyles  is  lessened  by  the  displacement  back- 
wards of  the  bone,  with  the  additional  shorten- 
ing, due  to  the  circumstance  that  the  line  between 
by  the  passing  of  the  femoral  head  above  the 
level  of  the  acetabulum.  The  adduction^  and 
inversion  in  the  main  depend  upon  the  position  of 
the  head  and  cervix,  which  must  follow  the  plane 


Fig.   108.  -  Obturator  or    thyroid 
dislocation.     {Bigeloiv.) 


XXI] 


DISLOCATIONS    OF    THE    HIP 


537 


of  the  bone  upon  which  they  lie.  This  position  is 
maintained  by  the  tense  Y  ligament.  The  damage 
done  to  the  chief  external  rotators  places  them  also 
hors  de  combat.  The  flexion  is  due  to  the  tension 
of  the  Y  ligament  and  of  the  ilio-psoas  muscle. 
Nos.    3   and   4  :    The  dislocation  forwards. — ] 


acetabulum    simply 


the    head    after    leaving 

moves     a     little     for- 
wards along  the  inner 

edge  of  the  socket,  the 

thyroid      luxation      is 

produced     (Fig.     108). 

If  it  goes  farther  and 

moves     upwards,     the 

pubic     displacement 

will  result  (Fig.   109). 

The  latter  dislocation 

is    therefore    but    an 

advanced  form  of  the 

former.      Whether   the 

head  will  remain  in 
the  thyroid  foramen 
or  ascend  on  to  the 
pubes  depends  on 
whether  extension  and 
rotation  outwards  ac- 
company the  displace- 
ment. If  these  occur 
the  pubic  form  is 
produced.  In  these 
injuries  the  pectineus, 
gracilis,  and  adductors 
will  be  more  or  less  torn, 
while  the  ilio-psoas,  glutei,  and  pyriform  muscles 
are  much  stretched.  The  obturator  nerve  may  be 
stretched  or  torn,  and  in  the  pubic  luxation  the 
anterior  crural  nerve  may  be  involved.  The  ab- 
duction and  eversion  of  the  limb  noticed  in  these 
luxations  depend  partly  upon  the  position  of  the 
head  of  the  bone,  fixed  more  or  less  by  the  Y  liga- 
ment, and  partly  upon  the  action  of  the  gluteal 
muscles  and  some  of  the  small  external  rotators, 


Fig.    109.— Dislocation   upon 
the  pubes.     (Bigelow.) 


538  THE    LOWEE    EXTREMITY  [Chap. 

which  are  tightly  stretched.  The  flexion  of  the 
limb  is  mainly  due  to  the  stretching  of  the  ilio- 
psoas muscle. 

In  the  thyroid  luxation  the  extremity  is  said 
to  be  lengthened.  This  lengthening  is,  however, 
only  apparent,  and  is  due  to  the  tilting  down  of 
the  pelvis  on  the  injured  side.  In  the  pubic 
dislocation  there  is  shortening,  the  head  being 
carried  above  the  acetabular  level. 

Of  the  modes  of  reducing  these  dislocations 
by  manipulation  little  can  be  said  here.  The 
more  usual  proceedings  may  be  briefly  summarized 
as  follows  : 

First. — Flex  the  thigh  in  the^ 
adducted      position 
in    luxations    Nos.  I 
1  and  2.  1  To     relax    the 

Flex  the  thigh  in   the  f    ligament, 
abducted      position 
in     luxations     Nos. 
3   and  4. 

ci  77        r\-  j  ,    .    /To  bring  back  the 

S^o^.-Circumduct  out  in     head  t*  the   rent 

Nos.  1  and  2.    .    J   in  the  ule  b 

Circumduct   in    in     fVlQ  oarna   *hot  fllQJf 


Nos.   3  and  4. 


the  same  route  that 
it  has  escaped. 
Thirdly. — Extend    in    all    cases.     To    induce    the 
head  to  enter  the  acetabulum  again. 

In  reducing  dislocations  of  the  hip  it  may  be 
noted  that  the  internal  condyle  of  the  femur  faces 
in  nearly  the  same  direction  as  the  head  of  the 
bone. 

In  amputation  of  the  thigli  at  the  hip- 
joint  many  methods  may  be  employed,  but  there 
is  a  consensus  of  opinion  that  it  is  wise  to  design 
the  operation  so  that  the  femoral  vessels  may  be 
secured  in  the  preliminary  incision.  In  dis- 
articulation by  a  racquet-shaped  incision,  the 
part  representing  the  handle  is  placed  over 
the   upper  3   inches   of  the   femoral   artery,   com- 


XXI!  AMPUTATION    AT    HIP-JOINT  539 

mencing  above  at  Poupart's  ligament,  and  the 
elliptical  part  is  carried  round  the  inner  side  of 
the  limb,  4  inches  below  the  pubic  spine,  and 
brought  up  on  the  outer  side,  below  the  great 
trochanter.  The  surface  markings  for  the  femoral 
artery  are  given  at  p.  512;  the  origin  of  the  deep 
femoral  artery  and  its  circumflex  branches  lie 
about  lh  inches  below  Poupart's  ligament,  but 
it  is  frequently  i  an  inch  higher  or  lower.  The 
common  femoral  is  separated  from  the  capsule  of 
the  hip-joint  by  the  psoas  muscle;  the  femoral 
vein  lies  close  to  its  inner  side,  and  the  anterior 
crural  nerve  i  an  inch  to  its  outer  side,  on 
the  psoas  muscle.  Branches  of  the  sciatic  and 
obturator  arteries  also  enter  the  thigh  and  re- 
quire to  be  secured.  The  nerves  divided  are  : 
the  external,  middle  and  internal  cutaneous,  the 
internal  saphenous,  the  deep  muscular  branches 
of  the  anterior  crural,  the  obturator,  the  great 
and  small  sciatic.  The  muscles  divided  are  :  the 
sartorius,  quadriceps  extensor  cruris,  adductors 
magnus  and  longus,  ^  gracilis,  and  hamstrings. 
The  capsule  of  the  joint  is  divided,  the  head  of 
the  femur  thrust  from  its  socket,  and  the  liga- 
mentum  teres  cut.  The  attachments  of  the  follow- 
ing structures  to  the  upper  third  of  the  femur 
have  to  be  separated  :  the  gluteus  maximus, 
medius,  minimus,  pyriformis,  gemelli,  obturator 
internus  and  externus,  quadratus  femoris,  ad- 
ductor magnus,  brevis,  pectineus,  psoas  and  ilia- 
cus,  with  the  capsular  ligament. 


CHAPTER    XXII 

THE  THIGH 

Under  the  term  "  the  thigh  "  it  will  be  convenient 
to  describe  that  part  of  the  lower  limb  that  ex- 
tends between  the  regions  just  described  and  the 
districts  of  the  knee  and  popliteal  space.  ^ 

Surface  anatomy. — In  muscular  subjects  the 
outline  of  the  thigh  is  irregular,  but  in  the  less 
muscularly  developed,  who  are  provided  with  a 
good  share  of  subcutaneous  fat,  the  limb,  in  this 
section  of  it,  is  more  or  less  evenly  rounded.  The 
prominence  of  the  rectus  muscle  is  noticeable  on 
the  front  of  the  thigh,  especially  when  the  muscle 
is  in  action.  To  the  inner  side  of  this  structure, 
and  conspicuous  along  the  lower  half  of  the  thigh, 
is  the  eminence  formed  by  the  vastus  internus. 
The  mass  to  the  outer  side  of  the  rectus  is  com- 
posed of  the  external  vastus  muscle,  and  occupies 
the  greater  part  of  the  limb  in  this  region,  being, 
however,  more  conspicuous  below. 

Running  down  the  anterior  and  inner  aspect  of 
the  thigh,  from  the  apex  of  Scarpa's  triangle, 
is  a  depression  which  indicates  the  interval  be- 
tween the  quadriceps  muscle  and  the  adductors. 
Along  this  groove  the  sartorius  lies.  Over  the 
surface  of  the  vastus  externus  a  longitudinal  de- 
pression is  often  to  be  observed,  formed  by  the 
pressure  exercised  by  the  superimposed  ilio-tibial 
band  of  the  fascia  lata.  The  hamstring  muscles 
cannot  usually  be  distinguished  the  one  from  the 
other  above  the  popliteal  space,  nor  is  their 
540 


Chap.  XXII]  THE    THIGH  541 

separation  from  the  adductors  indicated.  The 
separation,  however,  between  them  and  the  vastus 
externus  is  distinct,  and  corresponds  to  the  posi- 
tion of  the  external  intermuscular  septum.  The 
line  of  the  femoral  vessels  has  already  been  given 
(p.  5J2).  The  long  saphenous  vein  follows  in 
the  thigh  the  course  of  the  sartorius  muscle,  and 
may  be  represented  on  the  surface  by  a  line  drawn 
from  the  region  of  the  saphenous  opening  (p.  512) 
to  the  posterior  border  of  the  sartorius  muscle 
at  the  level  of  the  inner  condyle  of  the  femur. 
The  long  saphenous  nerve  follows  the  course  of  the 
femoral  artery,  lying  first  to  the  outer  side  of  that 
vessel  and  then  gradually  crossing  it.  In  the 
lower  fourth  of  the  thigh  the  nerve  passes  under 
cover  of  the  sartorius  muscle  to  the  inner  side  of 
the  knee,  and  is  accompanied  by  the  superficial 
branch  of  the  anastomotic  artery.  A  line  drawn 
down  the  back  of  the  limb  from  a  point  midway 
between  the  great  trochanter  and  tuber  ischii  to 
the  middle  of  the  ham  will  correspond  to  the 
great  sciatic  nerve  and  one  of  its  continuations, 
the  internal  popliteal  (see  p.  504).  The  great  trunk 
usually  bifurcates  a  little  below  the  middle  of 
the  thigh. 

The  skin  of  the  thigh  is  coarse  on  the  outer 
side  of  the  limb,  but  internally  it  is  thin  and  fine, 
and  is  apt  to  be  readily  excoriated  by  ill-applied 
bandages  or  splints.  It  is  but  loosely  attached  to 
the  subjacent  parts,  a  circumstance  that  greatly 
favours  the  performance  of  circular  amputations 
in  this  region.  At  one  place,  however,  it  is  a 
little  more  adherent,  viz.  along  the  groove  that 
separates  the  vastus  externus  from  the  hamstring 
muscles,  and  that  corresponds  to  the  outer  inter- 
muscular septum.  The  laxity  of  the  subcutaneous 
tissue  favours  extensive  extravasations  beneath 
the  skin,  and  permits  of  large  flaps  of  integu- 
ment being  torn  up  in  cases  of  injury  to  this  part 
of  the  extremity. 

The  fascia  lata  invests  the  limb  at  all  parts 
like  a  tightly  fitting  sleeve.     It  is  thickest  at  its 


542  THE    LOWER    EXTREMITY  LChap. 

outer  side,  where  it  forms  the  dense  ilio-tibial 
band.  It  is  thinnest  at  the  upper  and  inner  as- 
pect of  the  thigh,  where  it  covers  the  adductor 
muscles.  It  increases  considerably  in  strength  as 
it  approaches  the  front  of  the  knee,  and  attaches 
itself  to  the  tibia  and  lateral  margins  of  the 
patella.  This  fascia  resists,  especially  at  its  outer 
part,  the  growth  of  tumours  and  abscesses,  and 
limits  deep  extravasations  of  blood.  It  has  occa- 
sionally been  ruptured  in  part  by  violence,  and 
through  the  rent  so  formed  the  subjacent  muscle 
has  bulged,  forming  what  is  known  as  a  hernia 
of  the  muscle.  This  condition  has  been  met  with 
in  the  case  of  the  quadriceps  muscle,  and  also 
of  the  adductor  longus.  Such  "  hernise  "  are 
probably  associated  with  some  rupture  of  the  fibres 
of  the  muscles  implicated.  Two  deep  processes 
of  the  fascia  are  attached  #  to  the  femur,  and 
form  the  outer  and  inner  intermuscular  septa. 
The  outer  septum  separates  the  vastus  externus 
from  the  biceps,  and  the  inner  the  vastus  internus 
from  the  adductors.  ^  Together  with  the  fascia 
lata,  these  septa  divide  the  thigh  into  two  apo- 
neurotic spaces,  which  can  be  displayed  '  in  a 
transverse  section  t  of  the  limb.  These  divisions, 
however,  are  of  little  surgical  moment,  and  the 
inner  septum  is  often  so  thin  and  feeble  that  it 
could  have  but  little  effect  in  directing  the  course 
of  an  abscess. 

In  circular  amputations  of  the  thigh  the 
muscles  are  apt  to  retract  unevenly,  since  some 
are  attached  to  the  femoral  shaft  while  others 
are  free.  The  muscles  so  attached  are  the  ad- 
ductors, vasti,  and  crureus,  while  the  free  mus- 
cles are  the  sartorius,  rectus,  hamstrings,  and 
gracilis. 

In  spite  pi  its  great  strength  the  tendon 
of  the  quadriceps  may  be  ruptured  by  muscular 
violence.  A  good  example  of  such  an  accident 
is  recorded  by  Mr.  Bryant  (Med.  Times  and  Gaz., 
1878).  A  man  aged  42  stumbled  and  fell  down  a 
pit  10  feet  deep.     On  examination  the  tendon  was 


XXII]  FEMORAL    ARTERY  543 

found  to  be  torn  across,  and  the  gap  above  the 
patella  produced  by  the#  rupture  occupied  no  less 
extent  than  the  lower  third  of  the  thigh.  A  some- 
what more  remarkable  accident  is  reported  to  have 
happened  to  the  sartorius  muscle.  This  muscle, 
just  before  its  insertion  into  the  tibia,  gives  off 
an  aponeurotic  expansion  from  its  anterior  bor- 
der to  the  capsule  of  the  knee-joint.  In  the  case 
alluded  to  (Lancet,  1873),  this  expansion  is  said 
to  have  been  ruptured,  and  the  muscle  itself  to 
have  been  found  dislocated  backwards  in  con- 
sequence. The  accident  befell  a  man  aged  40, 
who  was  squatting,  in  the  position  assumed  by 
tailors,  upon  the  floor  of  a  wagon,  when  his  com- 
panion tripped  over  him  and  fell  across  his  bent 
knees.  Something  was  felt  to  have  given  way 
near  the  ham,  and  on  examination  the  above  lesion 
was  diagnosed. 

The  femoral  artery  may  be  ligatured  at  any 
part  of  its  course  in  the  thigh,  and  the  com- 
paratively superficial  position  of  the  vessel  ren- 
ders it  very  liable  to  be  injured.  In  the  middle 
third  of  the  thigh  it  lies  beneath  the  sartorius  in 
Hunter's  canal.  The  thigh  affords  many  instances 
of  the  remarkable  way  in  which  isolated  branches 
of  a  main  artery  are  often  alone  damaged.  Thus, 
Langier  relates  the  case  of  a  man-cook,  who,  in 
running  round  a  table,  struck  the  upper  and 
outer  side  of  his  thigh  against  the  corner  of  it. 
This  led  to  a  subcutaneous  rupture  of  the  external 
circumflex  artery.  Unfortunately  the  extravasa- 
tion was  cut  into,  and  the  patient,  after  being 
subjected  to  many  modes  of  treatment,  died  from 
the  effects  of  repeated  haemorrhage.  Dr.  Butcher 
(Dub.  Journ.  Med.  Sci.,  1874)^  gives  the  case  of  a 
man  who  was  stabbed  in  the  thigh  over  the  femoral 
vessels  during  a  scuffle.  Profuse  bleeding  fol- 
lowed, and  it  was  found  that  the  only  vessel 
wounded  was  the  internal  circumflex  artery,  just 
at  its  point  of  origin  from  the  profunda.  The 
case  was  treated  promptly,  and  the  man  did 
well. 


544  THE    LOWER    EXTREMITY  LChap. 

Fractures  of  the  femur. — The  shaft  of  the 
femur  may  be  broken  at  any  part,  but  the  lesion 
is  most  common  at  the  middle  third  of  the  bone, 
and  least  frequent  at  its  upper  third.  If  broken 
by  direct  violence  the  fracture  is  usually  trans- 
verse, and  if  by  indirect  violence  it  is  usually 
oblique.  The  probability  of  a  fracture  being  due 
to  direct  violence  diminishes  in  the  bone  from 
below  upwards,  while  the  probability  of  a  lesion 
from  indirect  violence  increases  in  the  same  direc- 
tion. Thus  it  happens  that  the  fractures  of  the 
upper  third  of  the  bone  are  usually  oblique,  while 
those  of  the  lower  third  are  more  commonly  trans- 
verse. In  the  middle  third  the  numbers  of  the 
transverse  and  oblique  fractures  are  more  nearly 
balanced.  The  femur  has  often  been  broken  by 
muscular  violence,  but  it  is  doubtful  if  this 
has  ever  occurred  in  other  than  a  diseased  bone. 
In  many  of  these  cases  the  amount  of  force 
that  breaks  the  bone  is  most  insignificant.  Thus, 
Vallin  reports  the  case  of  a  girl  aged  18,  de- 
scribed as  robust,  who  broke  the  femur  about  its 
middle  while  in  the  act  of  mounting  a  table  for 
the  purpose  of  undergoing  a  vaginal  examination. 
In  oblique  fractures  in  the  upper  third  of  the  bone 
the  line  of  fracture  usually  runs  downwards  and 
inwards,  while  in  oblique  fractures  of  the  middle 
third  the  direction  is  more  commonly  downwards 
and  forwards,  with  a  slight  lateral  inclination 
that  is  sometimes  inwards  and  sometimes  out- 
wards. Fractures  of  the  lower  third  of  the  bone 
are  discussed  in  connexion  with  the  region  of  the 
knee  (Chap,  xxiii.). 

With  regard  to  fractures  of  the  upper  and 
middle  thirds,  the  displacements  of  the  fragments 
depend  greatly  upon  the  obliquity  of  the  fracture. 
As  a  rule  the  lower  fragment  is  drawn  up  behind 
the  upper  one  by  the  hamstrings,  aided  by  the 
rectus,  gracilis^  sartorius,  tensor  vaginae,  arid 
adductors,  and  is  carried  a  little  to  its  inner  side 
under  the  influence  of  the  last-named  muscles. 
The    lower   end   of   the   upper    fragment   usually 


XXII]  FRACTURES    OF    FEMUR  545 

projects  forwards  and  a  little  backwards.  This 
is  produced  by  the  agency  of  the  lower  fragment, 
which  tilts  the  upper  piece  of  bone  in  the  direction 
named.  In  the  fracture  of  the  upper  third  of  the 
shaft  the  projection  forwards  of  the  upper  frag- 
ment is  aided  by  the  ilio-psoas  muscle.  Thus  the 
deformity  produced  in  fractures  of  the  femoral 
shaft  is  usually  angular  in  character.  The  ever- 
sion  of  the  foot  noted  in  fractures  of  the  femur  is 
due  to  the  weight  of  the  limb,  which  causes  the 
helpless  member  to  roll  out,  aided  probably  by  the 
action  of  the  external  rotator  muscles. 

Certain  spiral  fractures  (helicoidal  fractures 
of  Leriche)  may  be  produced  in  the  lower  part  of 
the  shaft  as  the  result  of  torsion.  M.  Fere  finds 
by  experiment  that  if  the  limb  be  carried  forwards 
in  front  of  the  opposite  knee,  and  the  foot  rotated 
outwards,  a  spiral  fracture  can  be  produced  at  the 
junction  of  the  lower  and  middle  thirds  of  the 
femur.  A  like  fracture  at  the  same  level,  but 
with  the  direction  of  the  spiral  reversed,  can  be 
produced  by  carrying  the  limb  outwards  and  then 
rotating  it  inwards. 

Shortening  of  the  limb  after  fracture.— 
It  is  doubtful  if  a  fracture  of  the  shaft  of  the 
femur  can,  after  any  treatment,  become  united 
without  some  shortening  resulting,  save  in  a  few 
exceptional  cases.  It  is  important,  in  connexion 
with  this  subject,  to  remember  that  the  lower 
limbs  may  be  normally  of  unequal  length.  Dr. 
Wight,  of  Brooklyn,  has  fully  investigated  this 
matter,  and  arrived  at  the  following  conclu- 
sions :  (1)  The  greater  number  of  normal  lower 
limbs  are  of  unequal  length ;  (2)  the  left  limb  is 
often  longer  than  the  right;  (3)  the  average  in- 
equality of  normal  lower  limbs  is  probably  about  J 
of  an  inch;  (4)  the  average  amount  of  shortening 
after  a  fracture  of  the  femur  that  has  been  well 
treated  is  about  f  of  an  inch ;  (5)  in  about  one  case 
in  ten  or  eleven  the  two  limbs  will  be  found  to  be 
of  equal  length  after  the  union  of  the  fracture ; 
(6)  one  limb  can  never  be  a  certain  standard  of 
s 


546 


THE    LOWER    EXTREMITY 


[Chap 


length  for  the  opposite  limb.  Dr.  Garson,  as  a 
result  of  the  careful  examination  of  some  seventy 
skeletons,  states  that  both  the  lower  limbs  are  of 
equal  length  in  only  about  10  per  cent,  of  all  cases. 
He  also  found  that  the  femur  was  more  frequently 
the  seat  of  variation  than  the  tibia. 


,a        4 


Fig.  110. — Transverse  section  through  the  middle  of  the 
thigh.     (Braune. ) 

a,  Rectus  femoris  ;  b,  vastus  externus  ;  c,  crureus  ;  d,  vastus  internus  ; 
e,  short  head  of  biceps  ;/,  long  head  of  biceps  ;  g,  semitendinosus  ; 
h,  semimembranosus  ;  i,  adductor magnus  ;j,  gracilis  ;  A,  adductor 
longus ;  I,  sartorius.  1,  femoral  artery  ;  2,  great  sciatic  nerve  ; 
3,  great  saphenous  vein  ;  4,  middle  cutaneous  nerve  ;  5,  external 
cutaneous  nerve  ;  6,  perforating  branches  from  profunda ;  7, 
small  sciatic  nerve. 


Amputation  of  the  thigh.— As  already  men- 
tioned, the  unequal  contraction  of  the  muscles 
renders  a  circular  amputation  unsuitable  for  the 
thigh.  Hence  the  operation  preferred  is  one  in 
which  a  large  flap  is  formed  from  the  tissues  in 
front  of  the  thigh,  and  a  shorter  flap  from  the 
structures  on  the  posterior  aspect.     The  various 


XXII]  AMPUTATION    OF    THIGH  547 

structures  which  are  involved  and  the  relation- 
ship of  the  one  to  the  other  are  best  understood 
by  examining  a  section  of  the  thigh,  such  as  is 
shown  in  Fig.  110.  The  parts  cut  are  the  following  : 
the  quadriceps,  sartorius,  gracilis,  long  and  great 
adductors,  and  the  three  hamstring  muscles;  the 
superficial  and  deep  femoral  vessels,  the  descend- 
ing branches  of  the  external  circumflex  artery,  the 
lower  perforating  vessels,  and  the  long  saphenous 
vein ;  the  main  branches  of  the  anterior  crural 
nerve  (middle  cutaneous,  internal  cutaneous,  and 
muscular,  together  with  the  long  saphenous  nerve), 
the  anterior  branch  of  the  external  cutaneous 
nerve,  the  obturator,  and  the  great  and  small 
sciatic  nerves. 


CHAPTER  XXIII 

THE   REGION    OF   THE    KNEE 

In  this  chapter  will  be  considered  the  articulation 
of  the  knee,  the  soft  parts  about  the  joint,  the 
popliteal  space,  the  lower  end  of  the  femur,  the 
patella,  and  the  upper  ends  of  the  tibia  and  fibula. 

Surface  anatomy. — In  the  front  of  the  knee 
the  patella  can  be  distinctly  felt  and  seen.  Its 
inner  border  is  a  little  more  prominent  than  the 
outer.  When  the  limb  lies  in  the  extended  pos- 
ture, with  the  quadriceps  relaxed,  the  patella  can 
be  moved  to  and  fro,  and  appears  to  be  but  loosely 
attached.  When  the  quadriceps  is  contracted  the 
bone  is  drawn  upwards,  and  becomes  firmly  fixed 
against  the  femur.  In  flexion  of  the  joint  the 
patella  sinks  into  the  hollow  between  the  tibia  and 
the  intercondyloid  notch,  and  is  very  firmly  fixed. 
In  this  position  some  part  of  the  trochlear  surface 
of  the  femur  can  be  made  out  above  the  patella. 
On  each  side  of  the  knee-cap  a  hollow  exists  which 
may  be  completely  filled  up  with  fat  in  the  obese. 

When  the  limb  lies  in  the  extended  posture  the 
ligamentum  patellae  is  not  to  be  very  distinctly 
made  out.  It  becomes  a  little  more  conspicuous 
in  the  flexed  position,  and  is  most  prominent  when 
the  quadriceps  muscle  is  vigorously  contracted. 
The  subpatellar  pad  of  fat  bulges  outwards  on 
each  side  of  the  ligament  and  may  be  mistaken 
by  the  inexperienced  for  fluid  in  the  joint. 

On  the  inner  side  of  the  knee  the  following  parts 
can  be  felt  from  above  downwards  (Fig.  Ill)  :  the 
548 


Chap.  XXIII] 


THE    KNEE 


549 


tubercle  for  the  adductor  magnus,  and  the  tendon 
of  insertion  of  that  muscle;  the  inner  condyle  of 
the  femur,  which  is  very  prominent,  and  forms 
the  chief  part  of  the  rounded  eminence  on  this 
aspect  of  the  joint;  and  below  this  the  inner 
tuberosity  of  the  tibia.  Between  the  two  latter 
processes    of    bone,    the    interarticular    line    and 


Semitend. 
Poplit.  Art. 


Prepatel.   Bursa 
Synov.    Memb.  _J, 


Adduct.  Tub. 


\\  \      Sartorius 

Interart.  Cartil. 
Semimemb.   Bursa 


SUBSEMITEND.    BURSA 


Post.  Tib.   Art 
Ant.  Tib.  Art. 


Fig.    111. —  Surface   anatomy  of  the   inner   aspect    of  the 
knee-joint. 

semilunar  cartilage  are  easily  felt  (Fig.  111).  On 
the  outer  side  of  the  joint  is  the  external  condyle 
of  the  femur,  which  is  much  less  conspicuous  than 
its  fellow  of  the  opposite  side,  and  below  it  is  the 
corresponding  tuberosity  of  the  tibia,  forming  a 
marked  prominence.  Immediately  in  front  of  the 
biceps  tendon  the  upper  part  of  the  external 
lateral  ligament  can  be  felt  when  the  joint  is  a 
little  flexed.     Between  the  tendon  and  the  patella, 


550  THE    LOWER    EXTREMITY  [Chap. 

the  lower  part  of  the  ilio-tibial  process  of  the 
fascia  lata  can  be  detected  as  a  prominent  rounded 
band,  descending  to  the  external  tuberosity  of  the 
tibia.  It  is  most  distinct  when  the  knee-joint  is 
forcibly  extended  by  muscular  action,  and  often 
stands  out  conspicuously  beneath  the  skin.  The 
tubercle  of  the  tibia  and  the  head  of  the  fibula 
are  both  readily  felt,  and  are  nearly  on  the  same 
level. 

The  popliteal  space  only  appears  as  a  hollow 
when  the  knee  is  bent.  In  the  extended  limb  the 
hollow  is  replaced  by  an  evenly  rounded  eminence. 
The  crease  in  the  skin  that  passes  transversely 
across  the  ham  is  some  way  above  the  line  of  the 
knee-joint.  On  the  outer  side  of  the  space  the 
biceps  tendon  can  be  very  readily  felt,  especially 
when  the  muscle  is  in  action.  Just  behind  it,  and 
along  its  inner  border,  lies  the  peroneal  nerve. 
It  can  be  rolled  under  the  finger  as  it  crosses  the 
head  of  the  fibula  to  pass  beneath  the  peroneus 
longus  muscle.  On  the  inner  side  of  the  ham 
three  tendons  can  be  felt.  Nearest  to  the  middle 
of  the  space  is  the  long,  prominent  tendon  of 
the  semitendinosus.  Internal  to  it  is  the  larger 
and  less  distinct  semimembranosus  tendon,  and 
still  more  to  the  inner  side  the  gracilis  may  be 
made  out. 

The  popliteal  vessels  enter  the  ham  obliquely 
at  its  upper  and  inner  part,  and  under  cover  of 
the  semimembranosus  muscle.  The  outer  border  of 
this  muscle  is.  the  guide  to  the  upper  portion  of  the 
artery  (Fig.  111).  The  vessels  in  their  descent  reach 
a  point  behind  the  middle  of  the  knee-joint,  and 
then  pass  vertically  downwards.  The  termination 
of  the  popliteal  artery  is  on  a  level  with  the  lower 
part  of  the  tubercle  of  the  tibia.  When  the  limb 
is  flexed,  the  pulsations  of  the  artery  can  be  felt 
and  the  vessel  compressed  against  the  femur  a 
little  below  its  point  of  entry  into  the  popliteal 
space.  The  upper  articular  arteries  run  trans- 
versely inwards  and  outwards  just  above  the 
femoral    condyles.     The    lower    articular    arteries 


XXIIIj 


THE    KNEE  651 


are  also  placed  transversely,  the  inner  vessels 
running  just  below  the  internal  tuberosity  of 
the  tibia,  and  the  outer  just  above  the  head  of  the 
fibula.  The  deep  branch  of  the  anastomotica 
magna  descends  to  the  inner  condyle  of  the  femur 
in  the  substance  of  the  vastus  internus,  and  along 
the  front  of  the  adductor  magnus  tendon.  The 
internal  saphenous  vein  passes  up  along  the  back 
part  of  the  internal  condyle  of  the  femur,  and 
then  follows  the  sartorius  muscle  to  the  thigh. 
It  is  just  below  the  interarticular  line  that  the 
long  saphenous  nerve  usually  joins  the  vein.  The 
short  saphenous  vein  follows  the  middle  line  of 
the  calf  just  below  the  ham,  and  pierces  the  deep 
fascia  at  the  lower  part  of  the  popliteal  space. 
This  vessel  is  much  less  conspicuous  than  is  the 
long  saphenous  vein,  and  is,  indeed,  not  often  to 
be  seen  unless  varicose. 

The  internal  popliteal  nerve  descends  in  the 
middle  line,  and  continues  the  line  that  marks 
the  course  of  the  great  sciatic  trunk. 

In  their  normal  condition  the  popliteal  glands 
are  not  to  be  felt. 

The  limits  of  the  synovial  membrane  of  the 
knee-joint,  and  the  position  of  the  various  bursae 
about  this  articulation,  will  be  dealt  with  in  some 
of  the  subsequent  paragraphs. 

Front  of  the  knee. — The  skin  over  the  front 
of  the  knee  is  dense  and  very  movable.  This 
mobility  affords  considerable  protection  to  the 
knee-joint,  especially  in  stabs  with  bluntish  in- 
struments, and  in  any  injury  where  the  gliding 
movement  of  the  skin  may  direct  the  violence  away 
from  the  articulation.  The  comparative  looseness 
of  the  integument  is  sometimes  utilized  t  in  the 
operation  of  removing  so-called  "  loose  cartilages  " 
from  the  knee-joint.  It  permits  the  incision  into 
the  joint  to  be  very  indirect,  and,  the  skin  being 
dragged  out  of  place  during  the  operation,  it 
follows  that,  when  the  procedure  is  complete,  the 
surface  wound  and  that  in  the  knee  capsule  no 
longer  correspond.     In  flexion,  the  skin  is  drawn 


552  THE    LOWER    EXTREMITY  [Chap. 

tightly  over  the  patella,  and,  as  is  the  case  else- 
where, where  the  integument  lies  more  or  less 
directly  upon  the  bone,  a  contusion  over  the  knee- 
cap may  produce  a  lesion  precisely  like  an  in- 
cised wound. 

In  the  Lancet  for  1877  is  recorded  the  case  of 
a  very  stout  woman,  aged  57,  who,  stumbling 
on  a  hard  road,  fell  upon  her  bent  knee.  The 
skin  was  burst  across  the  front  of  the  knee, 
and  a  wound  was  produced  that  was  7  inches  in 
length,  and  was  as  cleanly  cut  as  if  made  by  a 
scalpel. 

There  is  but  little  subcutaneous  fat  in  front  of 
the  articulation,  and  thus  it  happens  that  in  am- 
putations through  the  knee-joint  the  anterior  flap 
is  very  thin,  and  is  composed  of  little  other  than 
the  simple  integument. 

As  blisters,  and  various  forms  of  counter- 
irritant,  are  often  applied  to  the  front  of  the  knee 
in  cases  of  disease,  it  may  be  well  to  take  note  of 
the  blood  supply  of  this  part,  and  of  the  relations 
between  the  surface  vessels  and  nerves  and  those  of 
the  joint.  The  vessels  that  give  branches  to  the 
front  of  the  knee,  and  are  concerned  in  the 
supply  of  the  part  to  which  blisters  are  usually 
applied,  are  the  anastomotic,  the  four  articular 
branches  of  the  popliteal,  and  the  anterior  tibial 
recurrent.  Now,  of  these  arteries,  and  especially 
of  the  anastomotica  magna  and  superior  articular, 
it  may  be  said  that,  shortly  after  their  origin, 
they  divide  into  two  branches,  or  two  sets  of 
branches,  one  going  to  the  surface  and  the  other 
to  the  articulation  of  the  knee  and  deeper  parts 
about  it.  It  may  be  supposed,  therefore,  that,  in 
applying  &  counter-irritant  in  front  of  the  knee 
for  the  relief  of  a  joint  affection,  a  greatly  in- 
creased quantity  of  blood  is  drawn  into  the  super- 
ficial divisions  of  the  above-named  vessels,  and  less 
blood  is  thereby  left  to  flow  by  their  deeper 
branches  to  the  seat  of  disease.  The  skin  over  the 
front  of  the  knee,  the  anterior  parts  of  the  joint, 
and  the  quadriceps  are  supplied  from  the  third  and 


XXIII]  FRONT    OF    THE    KNEE  553 

fourth  lumbar  segments  through  branches  of  the 
anterior  crural  and  obturator  nerves. 

The  superficial  lymphatics  in  the  region  of  the 
knee  lie  for  the  most  part  on  the  inner  aspect  of 
the  joint,  and  follow  the  course  of  the  long 
saphenous  vein.  Ulcers,  and  other  inflammatory 
affections  of  the  skin  over  the  articulation,  are 
more  apt  to  be  associated  with  lymphangitis  and 
with  enlargement  of  the  inguinal  glands  when 
situate  on  the  inner  aspect  of  the  joint  than  when 
placed  in  front  or  to  the  outer  side  of  it. 

The  bursas  over  the  front  of  the  knee  are  :  (1) 
The  patellar  bursa,  a  large  sac  placed  in  front 
of  the  patella  and  upper  part  of  the  patellar  liga- 
ment, separating  those  structures  from  the  skin 
(Fig,  111).  It  is  frequently  divided  by  septa  into 
superficial  and  deep  compartments.  It  is  very 
often  found  enlarged  in  those  who  kneel  much — 
in  housemaids,  stonemasons,  >  religieuses,  etc.  The 
parts  about  are  well  supplied  with  nerves,  and 
hence  much  pain  is  usually  associated  with  acute 
inflammation  of  this  sac.  It  is  in  close  contact 
with  the  patella,  and,  in  one  case  reported  by 
Erichsen,  suppuration  of  the  bursa  led  to  caries 
of  that  bone  (Figs.  112,  113,  and  117).  (2)  There  is 
a  bursa  between  the  patellar  ligament  and  the 
tubercle  of  the  tibia  (Fig.  113).  When  inflamed, 
it  causes  more  pain  than  is  observed  in  affections 
of  the  previous  bursa,  since  it  is  firmly  compressed 
between  two  rigid  structures,  the  ligament  and  the 
bone.  It  is  separated  from  the  synovial  cavity 
by  the  pad  of  fat  that  lies  behind  the  patella. 
(3)  The  bursa  between  the  quadriceps  tendon  and 
the  femur  will  be  considered  in  connexion  with 
the  synovial  cavity. 

Popliteal  space.— The  skin  over  the  space 
is  not  so  movable  as  is  that  over  the  front  of 
the  knee.  When  destroyed  by  injury,  by  burns, 
or  by  extensive  ulceration,  the  contraction  of  the 
resulting  cicatrix  may  lead  to  a  rigidly  bent 
knee.  The  skin  in  this  place  has  also  been  rup- 
tured by  forcible  extension  applied  to  the  limb  in 
s* 


554  THE    LOWER    EXTREMITY  [Chap. 

cases  of  contracted  knee.  Beneath  the  skin  and 
superficial  tissue  is  the  popliteal  fascia,  a  dense 
membrane  that  covers  in  the  space.  It  is  but 
a  continuation  of  the  fascia  lata  of  the  thigh, 
and  is  continuous  below  with  the  fascia  of  the  leg. 
It  passes  without  bony  attachment  over  the  ham- 
string muscles  that  bound  the  ham.  This  fascia 
limits,  often  in  a  very  marked  manner,  the  pro- 
gress of  popliteal  abscesses  and  growths  towards 
the  surface.  Its  unyielding  character  is  a  prime 
cause  in  the  production  of  the  severe  pain  with 
which  such  collections  and  tumours  are  often 
associated.  The  popliteal  abscess,  unable  to  reach 
the  surface,  is  encouraged  to  extend  either  up 
into  the  thigh  or  down  the  leg.  The  ham  may 
hold  a  very  considerable  quantity  of  pus.  Vel- 
peau  has  seen  a  case  where  a  litre  (1  pint,  15  oz.) 
of  pus  was  evacuated  from  this  region  in  a 
patient  who  presented  before  the  operation  but  an 
insignificant  swelling  in  the  site  of  the  collection. 
Duplay  records  two  cases  of  ulceration  of  an  ab- 
scess into  the  popliteal  artery,  and  Ollivier  an 
instance  where  the  abscess,  unable  to  find  a  way  to 
escape,  ultimately  entered  the  knee-joint. 

Pus  may  reach  the  ham  from  the  buttock  or 
pelvis  by  following  the  great  sciatic  nerve,  or  may 
extend  from  the  thigh  through  the  opening  in  the 
great  adductor  for  the  femoral  vessels. 

The  hamstring  muscles  are  frequently  found 
contracted  in  neglected  cases  of  knee-joint  disease, 
and  produce*  thereby  more  or  less  rigid  flexion 
of  the  leg  upon  the  thigh.  Irritation  from 
disease  of  the  knee-joint  may  lead  to  contracture 
of  the  hamstring  muscles.  These  muscles  are  sup- 
plied through  the  great  sciatic  nerve  from  the 
fifth  lumbar  segment,  from  which  the  knee-joint 
derives  in  part  its  nerve  supply.  Muscles  on  the 
flexor  aspect  of  a  bent  joint  undergo  a  permanent 
shortening  if  the  position  be  maintained  for  a  con- 
siderable space  of  time. 

Contraction  of  these  muscles  in  knee-joint  dis- 
ease tends  not  only  to  flex  the  knee  but  also  to 


XXIII]  VESSELS    OP    THE    HAM  555 

draw  the  tibia  backwards,  and  produce  in  some 
cases  a  partial  luxation. 

The  hamstring  tendons  may  be  ruptured  by 
violence,  the  tendon  most  frequently  torn  being 
that  of  the  biceps.  The  muscles  i  are  greatly 
stretched  when  the  trunk  is  bent  forcibly  forwards 
at  the  hip-joint,  the  knee  remaining  extended. 
Extreme  movement  in  this  position  has  ruptured 
some  of  the  fibres  of^  this  muscle.  The  difficulty 
experienced  in  touching  the  toes  with  the  fingers 
while  the  knees  are  kept  stiff  depends  upon  the 
resistance  offered  by  the  stretched  hamstrings.  In 
tenotomy  of  the  biceps  tendon  the  peroneal  nerve 
is  in  great  risk  of  being  wounded.  It  may  be 
noted  that  contraction  of  the  muscle  tends  to 
increase  the  distance  between  the  tendon  and  the 
nerve,  and  to  render  the  former  more  superficial. 
The  peroneal  nerve  may  be  compressed  by  band- 
ages or  garters  applied  too  tightly  over  the  head 
or  neck  of  the  fibula. 

Vessels  of  the  ham.  — The  popliteal  vessels 
are,  from  their  depth,  but  seldom  wounded.  It 
must  be  borne  in  mind  that  the  lower  part  of 
the  artery  may  be  reached  from  the  anterior 
aspect  of  the  leg  by  an  instrument  passing  between 
the  tibia  and  fibula.  Thus,  S  pence  reports  the 
case  of  a  farmer  who  received  a  wound  in  front 
of  the  leg5j  just  below  the  knee,  from  the  slipping 
of  his  knife  while  cutting  a  stick.  It  was  dis- 
covered subsequently  that  the  knife  had  entered 
the  interosseous  space  and  had  wounded  the  pop- 
liteal artery  at  its  bifurcation.  It  had  indeed 
nearly  severed  the  anterior  tibial  artery  from  the 
main  trunk. 

The  popliteal  artery  has  been  ruptured  by  ex- 
ternal violence,  as  when  a  wheel  has  passed  over 
the  region  of  the  vessel.  This  artery  is  more  fre- 
quently the  seat  of  aneurysm  than  is  any  other 
artery  in  the  body,  save  only  the  thoracic  aorta. 
In  551  cases  of  spontaneous  aneurysm,  collected 
by  Crisp,  the  popliteal  vessel  was  the  seat  of  the 
disease  in  137  instances,  the  thoracic  aorta  having 


556  THE    LOWER    EXTREMITY  [Chap. 

been  affected  in  175  of  the  cases.  This  marked 
disposition  to  aneurysm  depends  upon  many 
factors.  The  vessel  is  subjected  to  a  great  deal 
of  movement,  and  often  to  very  violent  movement. 
Experiments  upon  the  dead  body  show  that  the 
inner  and  middle  coats  of  the  vessel  may  be  rup- 
tured by  extreme  flexion  of  the  knee,  and  that  a 
like  rupture  may  in  a  smaller  percentage  of  cases 
be  brought  about  by  forcible  extension^  More- 
over, except  when  the  limb  is  in  the  position  of 
extension,  the  popliteal  artery  is,  like  the  thoracic 
aorta,  much  curved.  Then,  again,  the  vessel 
breaks  up  into  two  large  vessels,  and  it  is  well 
known  that  the  point  of  bifurcation  of  an  artery 
is  a  favourite  spot  for  aneurysm.  Lastly,  the 
artery  is  supported  only  by  the  lax  tissue  of  the 
popliteal  space,  and  the  support  of  strong  muscles 
given  elsewhere  to  so  many  large  vessels  is  practi- 
cally absent.  Some  popliteal  aneurysms  have  been 
successfully  treated  by  flexing  the  knee  and  retain- 
ing the  limb  for  some  time  in  that  position.  That 
flexion  can  have  a  direct  effect  upon  the  lumen  of 
the  vessel  is  shown  by  the  diminished  pulse  at  the 
inner  ankle  produced  by  forcibly  bending  the  leg 
upon  the  thigh.  (  The  artery  and  vein  are  so 
adherent  that  it  is  difficult  to  separate  the  two 
when  applying  a  ligature  to  the  arterial  trunk. 
This  adhesion  must  have  been  appreciated  by  any 
who  have  taken  pains  to  "  clean  "  the  artery  in  a 
dissection  of  the  ham. 

The  popliteal  vein  is  a  remarkably  substantial 
vessel,  and  has  walls  so  dense  and  thick  that  on 
section  they  often  look  more  like  the  tunics  of  an 
artery.  On  the  ground  of  this  peculiarity,  and  of 
its  close  adhesion  to  its  companion  vessel,  Tillaux 
asserts  that  "  it  is  unlike  any  other  vein  in  the 
economy."  It  is  worthy  of  note  that  the  vein, 
although  more  superficial  than  the  artery,  is  very 
rarely  ruptured  by  violence.  As  a  rule,  the  artery 
alone  is  torn.  In  a  few  cases <  both  the  vessels 
may  suffer;  but  I  can  find  no  instance  recorded 
of  rupture  of  the  popliteal  vein  alone. 


XXIII]  THE    HAM  8Sf 

From  the  relations  of  the  artery  to  the  vein 
and  nerve  it  will  be  understood  that  a  popliteal 
aneurysm  may  soon  lead  to  oedema  of  the  leg  and 
to  nerve  symptoms  depending  upon  pressure  on 
the  internal  popliteal  trunk.  It  has  more  than 
once  also  made  its  way  into  the  knee-joint,  with 
the  posterior  ligament  of  which  the  artery  is  in 
such  close  relation. 

The  short  saphenous  vein  lies  almost  in  the 
middle  line,  and,  not  being  usually  apparent 
through  the  skin,  may  be  divided  in  an  incision 
made  into  the  lower  part  of  the  popliteal  space. 

The  lymphatic  glands  in  the  ham  are  from 
four  to  five  in  number  and  are  deeply  placed 
about  the  great  vessels.  When  enlarged  they  have 
been  mistaken  for  aneurysm  and  other  popliteal 
tumours.  They  receive  the  deep  lymphatics  of 
the  leg.  A  small  gland  is  often  met  with  beneath 
the  fascia,  close  to  the  point  of  entry  of  the  short 
saphenous  vein.  It  receives  some  lymphatics  that 
follow  that  vessel. 

The  bursas  about  the  <  ham  are  usually  seven 
in  number,  four  on  the  inner  side  of  the  space 
and  three  on  the  outer.  Inner  side. — (1)  A  large 
bursa  between  the  internal  condyle  of  the  femur 
and  the  inner  head  of  the  gastrocnemius  and  the 
semimembranosus  (Fig.  111).  This  is  the  largest 
bursa  in  the  space,  and  after  adult  life  it  usually 
communicates  with  the  joint.  It  is,  of  all  the 
bursas  in  this  region,  the  one  most  often  enlarged, 
and  when  affected  may  attain  great  size.  In  one 
reported  case  the  sac  measured  5  by  3^  inches. 
In  the  extended  position  of  the  limb  the  enlarged 
bursa  feels  firm  and  resistant,  but  on  flexion  it 
becomes  flaccid  and  can  often  be  made  entirely  to 
disappear.  Probably  the  slit-like  communication 
between  the  bursa  and  the  joint  is  closed  when 
the  posterior  ligament  is  tightened  by  extension, 
and  is  opened  when  it  is  relaxed  on  bending  the 
knee.  In  the  latter  posture  the  contents  of  the 
bursa  can  be  reduced  into  the  cavity  of  the  knee- 
joint,  and  so  the  tumour  disappears.     (2)  A  little 


m  THE    LOWER    EXTREMITY  [Chap. 

bursa  between  the  semimembranosus  tendon  and 
the  tuberosity  of  the  tibia.  Rather  below  the 
level  of  the  knee  there  are  two  further  bursae — (3) 
one  beneath  the  insertion  of  the  sartorius,  and 
(4)  another  beneath  the  insertions  of  the  gracilis 
and  semitendinosus.  Outer  side. — (1)  A  large 
diverticulum  of  the  synovial  membrane  of  the 
joint  between  the  popliteus  tendon  and  the  ex- 
ternal tuberosity  of  the  tibia.  This  diverticulum 
serves  the  purpose  of  a  bursa,  and  may  open  into 
the  tibio-fibular  articulation,  and  so  bring  that 
cavity  into  connexion  with  the  knee-joint.  (2)  A 
bursa  between  the  outer  head  of  the  gastrocnemius 
and  the  femoral  condyle.  It  is  not  constant  and 
is  not  connected  with  the  articulation.  (3)  A 
bursa  between  the  biceps  tendon  and  the  external 
lateral  ligament.  The  peroneal  nerve  runs  across 
this  sac,  a  circumstance  that  may  explain  some  of 
the  pain  experienced  when  the  bursa  is  enlarged. 

It  is  not  improbable  that  wounds  in  this  region 
of  bursse  containing  fluid  have  been  mistaken  for 
wounds  of  the  joint,  and  the  escaping  serum  for 
synovia. 

The  knee-joint  (Fig.  112). — This  articulation 
is  the  largest  in  the  body.  It  owes  its  great 
strength  to  the  powerful  ligaments  that  unite  the 
two  component  bones,  and  especially  to  the  muscles 
and  fascise  that  surround  it.  It  derives  no 
strength  from  the  shape  of  the  articular  surfaces, 
since  they  are  merely  placed  in  contact  with  one 
another.  In  spite  of  its  frequent  exposure  to  in- 
jury, dislocations  at  the  knee  are  extremely  rare. 
The  lateral  ligaments  are  comparatively  feeble, 
are  tense  in  extension  and  relaxed  in  flexion. 
The  laxity  of  these  ligaments  is  such  that  partial 
luxations  of  the  tibia  are  possible  without  rup- 
ture of  these  bands,  especially  in  cases  where  the 
joint  is  found  slightly  flexed  after  the  accident. 
The  crucial  ligaments  are  very  powerful,  and  are 
more  or  less  tense  in  all  positions  of  the  joint. 
The  anterior  of  these  ligaments  especially^  resists 
extension,  forward  displacement  of  the  tibia,  and 


XXIII] 


THE    KNEE-JOINT 


559 


rotation  inwards  of  the  leg.  The  posterior  band 
resists  flexion  and  displacement  backwards  of  the 
tibia.  In  the  movement  of  extension  the  tibia 
slides  a  little  forwards  and  is  rotated  a  little  out- 
wards. In  flexion  that  bone  glides  backwards  and 
rolls   a   little   inwards.       Extension    generally    is 


Fig.    112. — Vertical   section   of  normal   knee-joint. 

(Braune.) 

a,  Quadriceps  ;  &,  semimembranosus  ;  c,  gastrocnemius  ;  d,  posterior 
crucial  ligament ;  e,  ligamentum  patellae  ;/,  bursa  between  quad- 
riceps and  femur. 

limited  by  the  crucial  and  posterior  ligaments; 
flexion  by  the  ligamentum  patellae  and  anterior 
part  of  the  capsule,  in  addition  to  the  crucial 
ligaments.  Rotation  is  possible  only  in  the  flexed 
position.  The  thinnest  part  of  the  posterior  liga- 
ment is  the  portion  below  the  oblique  fibres  de- 
rived from  the  semimembranosus.  If  pus  should 
find    its    way    from    the    joint   into    the    ham,    it 


560  THE    LOWER    EXTREMITY  [Chap. 

will  probably  escape  through  this  part  of  the 
ligament. 

In  the  contracted  knee  associated  with  fibrous 
ankylosis,  the  chief  contraction,  so  far  as  the 
joint  tissues  are  concerned,  is  in  the  posterior 
ligament,  in  the  lateral  ligaments,  and  in  the 
fibrous  and  fatty  tissue  between  the  former  liga- 
ment and  the  posterior  crucial  band. 

The  synovial  membrane  of  the  knee-joint  ex- 
tends upwards  as  a  large  cul-de-sac  above  the 
patella  and  beneath  the  extensor  tendon.  This 
cul-de-sac  reaches  a  point  an  inch  or  more  above 
the  upper  margin  of  the  trochlear  surface  on  the 
femur,  and  is  rendered  very  distinct  when  the 
joint  is  distended  with  fluid  (Fig.  113).  When 
the  knee  is  bent  the  cul-de-sac  is  drawn  down, 
and  therefore  this  position  of  the  limb  is  advised 
when  operations  are  about  to  be  performed  upon 
the  lower  end  of  the  femur.  Above  the  synovial 
pouch  is  a  bursa  that  separates  the  quadriceps 
tendon  from  the  femur,  and  is  usually  over  an 
inch  in  its  vertical  measurement  (Fig.  113).  From 
the  examination  of  two  hundred  and  sixty  knee- 
joints  in  both  infants  and  adults,  Schwartz  found 
that  this  bursa  communicated  with  the  synovial 
cavity  in  seven  cases  out  of  ten  in  young  children, 
and  in  eight  cases  out  of  ten  in  adults. 

It  will  thus  be  seen  that  when  this  communica- 
tion exists,  a  stab  over  the  femur,  about  2  inches 
above  the  trochlear  surface  of  the  bone,  or  about 
the  same  distance  above  the  top  of  the  patella, 
when  the  limb  is  extended,  will  practically  open 
the  knee-joint. 

Cases  are  reported  of  extravasation  of  blood 
into  this  bursa  that,  although  at  first  limited  to 
the  sac,  have,  on  rough  handling,  extended  into 
the  knee-joint^— a  circumstance  leading  to  the  sup- 
position that  in  some  cases  the  orifice  of  communi- 
cation may  be  very  small. 

The  crucial  ligaments,  although  more  or  less 
completely  invested  by  the  synovial  membrane, 
are  yet  entirely  outside  the  synovial  cavity,  and 


XXIII] 


THE    KNEE-JOINT 


561 


divide  the  cavity  behind  into  an  outer  and  an  inner 
condylar  recess.  The  posterior  ligament  is  con- 
tinuous with  the  posterior  part  of  the  capsule. 


Fig.   113. — Vertical   section  of  knee-joint  distended  with 
fluid.     (Braune.) 

a,  Vastus  externus  ;  b,  crureus  ;  c,  shoit  head,  and  d,  long  head,  of 
biceps  ;  e,  plantaris  ;  /,  gastrocnemius  ;  g,  popliteus  ;  h,  soleus  ; 
t,  tibialis  posticus  ;  j,  bursa  patella) :  k,  ligamentum  patellae  ; 
I,  ligamentum  mucosum  ;  m,  anterior  crucial  ligament :  w,  exter- 
nal semilunar  cartilage.  1,  external  popliteal  nerve  ;  2,  popliteal 
artery. 

The  upper  third  of  the  patellar  ligament  is  in 
relation  to  the  synovial  membrane,  from  which, 
however,  it  is  separated  by  a  pad  of  fat.  The 
lower  two-thirds  of  the  ligament  are  in  rela- 
tion to  the  bursa  and  fatty  tissue  that  intervene 


562  THE    LOWER    EXTREMITY  [Chap. 

between  the  band  and  the  tibia.  A  knife  passed 
horizontally  backwards  at  the  apex  of  the  patella 
would,  when  the  limb  is  extended,  just  miss  the 
joint  line  between  the  femur  and  tibia,  and  would 
hit  the  latter  bone  (Fig.  112).  If,  however,  there 
be  any  effusion  in  the  joint,  or  the  limb  be  a  little 
flexed,  a  knife  so  introduced  would  pass  between 
the  two  bones  (Fig.  113).  Fringes  of  the  synovial 
membrane  (the  alar  ligaments)  fill  the  intervals 
between  the  articular  surfaces  of  the  patella  and 
femur.  Villous  processes  may  grow  out  from 
them,  become  detached,  and  form  loose  bodies  in 
the  joint.  That  such  processes  should  undergo 
chondrification  and  form  cartilaginous  bodies  is 
not^  surprising,  seeing  that  the  synovial  lining  is 
derived  from  the  same  tissue  as  forms  the  articular 
surfaces  of  the  bones  and  is  in  reality  merely  a 
finely  spread  layer  of  cartilage  covering  a  fibrous 
membrane. 

Joint  disease. — Owing  to  its  superficial  posi- 
tion the  knee-joint  is  the  articulation  that  is 
most  frequently  the  seat  of  inflammation  due  to 
injury  and  exposure  to  cold.  When  distended 
with  fluid,  the  effusion  soon  shows  itself  above 
and  at  the  sides  of  the  patella,  by  bulging  for- 
ward the  synovial  sac,  which  is  here  more  nearly 
in  relation  to  the  surface  than  it  is  elsewhere. 
Fluctuation  is  soon  to  be  detected,  and  the  patella, 
being  pushed  away  from  the  femur,  is  said  to 
"  float  v  upon  the  distending  fluid  (Fig.  113). 

The  inflamed  knee-joint,  if  left  to  itself,  almost 
invariably  assumes  the  flexed  position.  This  may 
be  explained  upon  three  hypotheses,  and  it  is 
probable  that  each  of  the  three  reputed  factors 
takes  part  in  producing  this  position  in  cases  of 
disease. 

1.  The  capacity  of  the  joint  is  increased  on 
flexion.  The  pain  of  acute  synovitis  is  due  mainly 
to  the  increasing  distension  of  the  joint  with  fluid, 
and  it  is  natural  that  the  patient  should  in- 
stinctively place  the  limb  in  the  position  in  which 
the  joint  will  hold  the  greatest  amount  of  fluid, 


XXIII]  SEMILUNAR    CARTILAGES  563 

and  in  which  the  interarticular  tension  is  reduced 
to  a  minimum.  Braune  found  that  the  maximum 
capacity  was  reached  when  the  knee  was  flexed  25°, 
and  the  minimum  on  complete  flexion. 

2.  By  flexing  the  limb,  the  more  powerful 
ligaments  (such  as  the  ligamentum  posticum,  the 
posterior  crucial  and  lateral  ligaments)  are  re- 
laxed, while  the  ligaments  rendered  tense  by  the 
position  are  the  patellar  and  the  anterior  part  of 
the  capsular,  the  latter  of  which  is  but  a  yielding 
membrane. 

3.  The  sensory  nerves  of  the  joint  being  dis- 
turbed, contraction  of  muscles  may  be  anticipated 
from  reflex  action,  and  of  the  muscles  so  excited 
the  flexors  may  be  expected  to  have  the  advantage, 
as  being  the  more  powerful  and  the  more  favour- 
ably placed  for  acting  upon  the  articulation. 

Dislocation  of  the  semilunar  cartilages. — One 
or  other  of  these  cartilages  may  be  displaced 
from  its  attachments  to  the  tibia,  and  become 
nipped  or  locked  between  that  bone  and  the  femur. 
The  result  is  a  sudden  pain  in  the  limb,  associated 
with  a  fixing  of  the  knee  in  a  flexed  position. 
The  accident  is  usually  brought  about  by  a  twist 
given  to  the  leg  when  the  knee-joint  is  more  or  less 
bent.  In  200  cases  of  internal  derangement  of 
the  knee-joint,  Bennett  found  that  the  internal 
cartilage  was  affected  in  155  cases  and  the  external 
in  only  45.  The  left  knee  was  the  seat  of  derange- 
ment nearly  three  times  as  often  as  the  right,  and 
the  lesion  occurred  nine  times  more  frequently  in 
men  than  in  women.  In  every  one  of  twelve  cases 
operated  on  by  Marsh,  the  anterior  extremity  of 
the  internal  semilunar  cartilage  was  found 
bruised  and  torn  from  its  tibial  attachment.  To 
understand  the  liability  to  injury  of  the  anterior 
part  of  the  internal  semilunar  cartilage,  it  is 
necessary  to  examine  the  manner  in  which  it  is 
maintained  in  position,  the  movements  which  it 
undergoes,  and  the  strains  to  which  it  is  sub- 
jected in  active  athletes — for  it  is  amongst  them 
that  displacements  most  frequently  occur.     In  the 


5G4 


THE    LOWER   EXTREMITY 


|  Chap. 


extended  position  of  the  knee,  displacement  is 
impossible,  for  the  cartilages  are  immovably 
fixed  by  the  coaptation  of  the  articular  surfaces, 
brought  about  by  the  tension  of  the  ligaments  and 
tonus  of  the  muscles  surrounding  the  joint.  When 
the  joint  is  partly  flexed  the  internal  cartilage  is  : 
fixed  (1)  by  its  anterior  horn  attached  to  the  tibia, 
above  and  behind  the  attachment  of  the  liga- 
mentum  patellae  and  outside  the  joint  cavity  (Fig. 
114) ;  (2)  by  the  transverse  ligament  to  the  anterior 
part  of  the  external  cartilage  (Fig.   114);   (3)  by 


Transverse  Lie, 

COROrtARy  Lie 

External  Semi  li 

A/it.Cruc 

Popliteus. 
Ext.Lat.Lii 
Biceps 


qawe/itum  Patellae 

Am.  AIor/i 

■COROrtARy  Liq. 

/iteraialSe/iilu/iar 

Cartilage 
/iTERrtAL  Lateral 
Liq. 

Post.  Crucial  Lie 
.Liq. 


Fig.  114. — Illustrating  the  fixation  and  movements  of  the 
semilunar  cartilages. 

The  position  of  the  internal  semilunar  cartilage  when  the  tibia  is 
rotated  outwards  or  femur  inwards,  is  shown  in  red. 


the  coronary  ligament  to  the  capsule  of  the  joint 
and  internal  lateral  ligament  :  the  anterior  fibres 
of  this  ligament  are  the  longest  (Fig.  114).  As  the 
joint  is  flexed  the  cartilages,  especially  the  in- 
ternal, glide  backwards;  if  in  this  position  the 
biceps  brings  about  a  sudden  rotation  outwards 
of  the  tibia,  the  anterior  horn  is  carried  forwards 
and  outwards  with  that  bone,  while  the  posterior 
is  firmly  fixed  to  the  internal  condyle  of  the 
femur  by  the  internal  lateral  ligament,  and  thus 
a  severe  strain  is  thrown  on  the  anterior  part 
of  the  internal  cartilage,  which  is  brought  into 
the  position  shown  in  Fig.  114.     Its  weakest  point 


XXIII]  GENU    VALGUM  565 

is  in  the  thin  inner  crescentic  margin  of  its  an- 
terior third,  and  it  is  here  that  partial  rupture 
usually  occurs.  The  intense  pain  is  due  to  the 
rupture  and  to  the  fact  that  the  strain  wedges 
the  cartilage  between  the  tibia  and  femur,  thus 
forcing  them  apart  and  causing  an  instant  and 
severe  hyperextension  of  the  unyielding  liga- 
ments of  the  joint.  The  external  cartilage  is 
smaller  than  the  internal,  is  rounder,  is  more 
movable,  and  possibly  on  these  accounts  is  less 
likely  to  be  "nipped"  between  the  bones.  It  is 
attached  in  part  to  the  femur  through  the  pos- 
terior crucial  ligament  and  is  grooved  f  by  the 
tendon  of  the  popliteus,  two  factors  which  add 
to  its  security  (Fig.    114). 

Genu  valgum,  or  knock=knee. — The  appearances 
produced  by  this  affection  are  familiar.  When 
a  person  stands  erect  with  the  feet  together, 
the  tibisB  are  practically  vertical,  and  the  femora 
meet  them  at  a  certain  angle.  The  degree  of  this 
angle  depends,  in  normal  subjects,  to  a  great 
extent  upon  the  relative  width  of  the  pelvis.  In 
genu  valgum  the  tibiae  cease  to  be  vertical  in  the 
erect  position ;  their  lower  ends  deviate  more  and 
more  from  the  middle  line,  until  the  distance  be- 
tween the  two  malleoli  becomes  considerable  when 
the  individual  stands  upright  and  when  he  is 
not  concealing  any  of  the  deformity  by  rotating 
the  limb. 

The^  progress  of  the  genu  valgum  may  be  di- 
vided into  three  stages.  In  the  first  stage  there 
is  a  yielding  or  elongation  of  the  internal  lateral 
ligament,  and  of  the  fascial  structures  on  the 
inner  side  of  the  joint.  That  the  yielding  of  this 
ligament  alone  will  permit  of  a  lateral  movement 
at  the  articulation  being  accomplished  is  illus- 
trated by  cases  of  sprains  of  the  knee,  where  the 
ligament  has  been  torn,  and  where  much  lateral 
bending  has  been  in  consequence  permitted.  It 
is  probable  that  the  crucial  ligaments  yield  also 
a  little,  and  it  is  upon  the  posterior  band  at- 
tached  to   the   internal   condyle   that   the   strain 


566 


THE    LOWEE    EXTREMITY 


[Chap. 


possibly  first  comes.  In  the  second  stage  there 
is  a  contraction  of  the  tissues  on  the  outer  side  of 
the  joint  that  have  been  relaxed  by  the  new  posi- 
tion of  the  limb  These  structures  are  the  ilio- 
tibial  band  of  the  fascia  lata,  the  external  lateral 
ligament,  and  the  biceps  tendon.  This  contrac- 
tion tends  to  give  permanency  to  the  deformity. 
In  the  third  stage  the  bones  become  changed. 
On  the  outer  side  of  the  joint  the  external  con- 
dyle  and  the  outer  tuberosity  of  the  tibia  are 
pressed    together,    and    through    these    bones    the 


Fig.  115. — A,  Normal  femur  ;  B,  femur  in  an  advanced 
state  of  knock-knee,  showing  the  enlargement  of  the 
internal  condyle. 

The  dotted  line  in  each  case  represents  the  line  of  the  epiphysis. 

greater  part  of  the  weight  of  the  body  will  be 
transmitted.  As  a  result  of  the  continual  pres- 
sure the  parts  waste  a  little,  and  by  their  atrophy 
contribute  not  only  to  the  extent  of  the  deformity 
but  also  to  its  permanency.  On  the  inner  side 
the  internal  condyle  tends  to  become  separated 
from  the  tibia,  and  an  interval  to  develop  be- 
tween the  two  bones  as  the  deformity  advances. 
This  interval  is  prevented  from  actually  existing 
by  the  development  of  the  condyle,  which  enlarges, 
and  so  still  maintains  its  contact  with  the  tibia. 
Mikulicz  has  pointed  out  that  "  the  alteration 
in  length  on  the  inner  side  of  the  femur  arises  not 


XXIII] 


FKACTURES    OF    PATELLA 


567 


Cb^r 


from  alteration  of  the  epiphysis,  but  is  confined 
to  the  lowest  part  of  the  diaphysis."  This  state- 
ment also  holds  true  for  the  tibia.  This  is  shown 
in  the  diagram  (Fig.  115),  where  it  will  be  seen 
that  the  enlargement  of  the  internal  condyle  is 
due  almost  entirely  to  increased  growth  in  the 
diaphysis.  The  increased  growth  does  not  affect 
the  antero-posterior  diameter  of  the  condyles. 
Hence,  when  the  knee  is  flexed,  all  trace  of  the 
deformity  disappears. 

Fractures  of  the  patella. — This  bone  is  more 
often  broken  by  muscular  violence  than  is  any 
other  in  the  body.  Although  the  patella  may 
be  fractured  by  both  mus- 
cular and  direct  violence, 
it  would  appear  that  the 
former  is  the  agent  that 
most  often  produces  the 
lesion.  Thus,  in  127  cases 
of  simple  transverse  frac- 
ture collected  by  Hamilton, 
he  considers  that  muscular 
action  was  the  cause  of  the 
injury  in  106  instances.  The 
form  of  fracture  due  to 
muscular  violence  is  very 
uniform.  It  is  nearly  al- 
ways transverse,  simple, 
and  through  the  centre  of 
the  bone,  or  just  above 
that  point  or  just  below  it. 
Fractures  due  to  direct  violence  may  present  the 
same  appearance,  but  they  are  more  often  starred, 
or  oblique,  or  even  longitudinal.  Experiments  upon 
the  cadaver  show  that  a  simple  transverse  frac- 
ture about  the  centre  of  the  bone  cannot  be  pro- 
duced with  any  degree  of  certainty  by  a  direct 
blow.  The  position  of  the  knee  that  most  favours 
fracture  by  muscular  action  is  that  of  flexion. 
When  the  knee  is  bent,  the  patella  rests  upon  the 
femoral  condyles  along  its  transverse  axis  only. 
Nearly  the  whole  of  its  upper  half  is  unsupported 


Fig.  116. — Diagram  to 
show  mechanism  of 
fracture  of  the  patella 
by  muscular  action. 

a,  Line  of  action  of  quadri- 
ceps muscle  ;  &,  femur  ;  c, 
tibia. 


568  THE    LOWER    EXTREMITY  [Chap. 

behind,  and  the  extensor  muscle  acts  in  a  line 
nearly  at  right  angles  to  the  vertical  axis  of  the 
bone.  Thus,  by  violent  contraction  of  the  quadri- 
ceps, the  patella  may  be  snapped  across  the  condyle 
as  a  stick  is  snapped  across  the  knee#  (Fig.  116). 
As  the  fracture  usually  causes  the  patient  to  fall, 
it  has  been  supposed  that  the  contact  with  the 
ground,  rather  than  any  previous  muscular 
action,  may  have  caused  the  lesion.  But,  as 
Hamilton  has  pointed  out,  if  a  person  falls  upon 
the  bent  knee  when  the  limb  also  is  flexed  upon 
the  trunk,  the  part  that  comes  in  contact  with 
the  ground  is  not  the  patella,  but  the  tubercle 
of  the  tibia. 

In  the  great  majority  of  cases  the  lesion  not 
only  involves  the  bone  but  also  the  cartilage  and 
fibrous  structures  that  cover  it  respectively  be- 
hind and  in  front;  the  synovial  membrane  also 
is  torn,  arid  the  patella  bursa  opened  up.  Thus 
the  synovial  contents  may  come  in  actual  contact 
with  the  skin.  "  It  is  anatomically  possible,  if 
the  fracture  involve  only  the  lower  and  non- 
articular  portion  of  the  patella,  and  if  the  amount 
of  the  separation  of  fragments  is  slight,  that  the 
fatty  tissue  behind  the  apex  of  the  patella,  over 
which  the  synovial  membrane  is  reflected  may 
save  the  latter  from  injury"  (Sir  Henry  Morris). 
In  all  cases  where  there  is  much  separation  of 
the  fragments,  the  fibrous  expansion  attached  to 
either  side  of  the  patella  must  be  torn  through. 
Indeed,  none  but  a  slight  separation  of  the  parts 
is  possible  until  that  expansion  is  ruptured. 
Braune  has  demonstrated  this  by  experiment,  by 
sawing  through  the  patella  without  damage  to 
the  lateral  ligamentous  structures,  and  noting 
that  but  trifling  separation  of  the  fragments  was 
possible  until  these  structures  had  been  divided. 
In  stellate  fractures,  due  to  direct  violence,  these 
fibrous  expansions  from  the  extensor  tendon  may 
be  uninjured,  and  no  separation  of  any  magni- 
tude be  permitted  between  the  portions  of  the 
broken  bone. 


XXTTT1 


FKACTUEES    OF    PATELLA 


5G9 


The  patella  is  more  readily  broken  by  muscular 
violence  than  is  either  the  extensor  tendon  or  the 
ligamentum  patellae.  In  the  flexed  position  it 
will  be  seen  (Fig.  116)  that  the  bone  is  placed 
at  a  considerable  disadvantage  when  compared 
with  the  two  other  structures.  Richet  reports  a 
case  where  violent  contraction  of  the  quadriceps 
caused  the  tubercle  of  the  tibia  to  be  torn  away 
from  the  bone  without  any  other  lesion  of  the  parts 
immediately  con- 
cerned  being 
produced. 

The  patella 
may  be  congen it- 
ally  absent.  It 
is  developed  in 
the  tendon  of 
the  quadriceps, 
remaining  carti- 
laginous until 
the  end  of  the 
second  year.  Its 
sesamoid  nature 
is  seen  in  the 
tendency  to  unite 
by  fibrous  rather 
than  by  bony 
union  after  frac- 
ture. It  receives 
its  blood  supply 
from  nearly  all 
the  arteries 
round  the  knee- 
joint. 

Dislocation 
of  the  patella. 
—This  bone  may 
be  dislocated  out- 
wards or  inwards,  or  turned  upon  its  edge 
so  that  its  anterior  and  posterior  surfaces  are 
placed  laterally.  The  luxation  outwards  is  by 
far   the   most   common.      This    depends   upon   the 


Fig.  117. — Transverse  section  of  left 
knee-joint  through  the  centre 
of  the  patella.     (Brmtne.) 

a,  Bursa  patellae  ;  &,  internal  lateral  liga- 
ment and  inner  condyle ;  c,  external 
lateral  ligament  and  outer  condyle  ; 
d,  biceps ;  e,  semimembranosus  ;  /, 
semi  tend  inosus  ;  g,  gracilis  tendon  ; 
It,  sartorius.  1,  internal  popliteal 
nerve  ;  2,  external  popliteal  nerve  ;  3, 
internal  saphenous  vein. 


570  THE    LOWER    EXTREMITY  [Chap. 

fact  that  the  quadriceps,  the  patella,  and 
the  ligamentum  patellae  do  not,  when  the 
muscle  is  contracted,  follow  the  lines  of  the  femur 
and  tibia.  They  are  more  nearly  in  a  straight 
line,  that  passes  to  the  outer  side  of  the  angle 
formed  by  the  femur  with  the  leg  at  the  knee- 
joint.  Muscular  contraction,  therefore,  tends  to 
draw  the  knee-cap  outwards,  a  tendency  that  is 
in  all  normal  circumstances  corrected  by  the  in- 
creased prominence  of  the  external  condyle.  The 
vastus  externus  also  is  said  to  be  more  powerful 
than  the  internus.  The  tensor  vaginae  femoris  has 
an  ^  attachment  to  the  patella  through  the  ilio- 
tibial  band.  By  the  sudden  action  of  this  muscle 
a  patient  of  Mr.  Rigby's  was  able  to  produce  a 
voluntary  outward  dislocation  of  the  patella. 
Dislocations  usually  occur  in  the  extended  posi- 
tion of  the  joint,  and  are  commonly  due  to  mus- 
cular action. 

In  the  dislocation  of  the  patella  upon  its  edge, 
the  inner  border  of  the  bone  usually  projects 
forwards,  while  the  outer  is  placed  between  the 
condyles.  But  little  is  known  as  to  the  mechanism 
of  this  dislocation. 

In  dislocations  of  the  knee,  which  are  very 
rare,  the  tibia  may  be  displaced  outwards,  in- 
wards, forwards,  or  backwards.  The  two  lateral 
luxations  appear  to  be  more  common  than  the 
antero-posterior.  The  former  are  nearly  always 
partial,  the  latter  usually  complete.  Consider- 
able violence  is  required  to  produce  these  luxa- 
tions, owing  to  the  great  strength  of  the  liga- 
ments and  muscles  and  the  great  width  of  the 
bones  involved.  Direct  violence  to  the  tibia  or 
femur,  associated  often  with  a  twisting  of  the 
former  bone,  is  the  common  cause  of  the  lesion. 
It  is  probable  that  in  all  luxations  of  the  knee 
the  crucial  ligaments  are  torn.  The  lateral  liga- 
ments also  are  usually  ruptured,  but  in  the 
partial  luxations  they  may  be  sometimes  found  to 
be  intact.  The  tendinous  expansion  of  the  vasti 
in  front  of  the  knee  seldom  escapes  some  lacera- 


XXIII]  LOWER    END    OP    FEMUR  571 

tion,  even  in  the  partial  dislocations.  The  pro- 
jection of  the  spine  of  the  tibia  between  the  femoral 
condyles  offers  an  obstruction  to  lateral  luxation. 
Dr.  F.  S.  Mackenzie  found  by  experiment  on  the 
dead  body  that  division  of  the  crucial  ligaments 
did  not  materially  influence  the  force  necessary 
to  produce  a  dislocation  at  the  knee-joint.  He 
found,  too,  that  in  seven  out  of  eight  experiments, 
dislocation  was  produced  and  not  fracture— 
whereas  in  life  fracture  is  by  far  the  commoner 
result.  He  concludes,  therefore,  that  the  strength 
of  the  joint  depends  on  the  surrounding  muscles 
rather  than  on  the  surrounding  ligaments.  The 
popliteal  vessels  and  nerves  are  much  compressed, 
and  appear  to  be  more  severely  injured  by  the 
femur  in  the  forward  dislocation  than  by  the 
tibia  in  the  backward  displacement. 

Lower  end  of  the  femur. — The  condylar  part 
of  the  femur  is  composed  almost  wholly  of 
cancellous  bone,  with  but  a  slight  layer  of  com- 
pact tissue.  It  is  so  spongy  that  it  may  be 
pierced  by  a  bullet,  as  pointed  out  by  Legouest, 
without  any  splintering  of  the  bone  being  pro- 
duced and  without  damage  to  the  articulation. 
The  fractures  that  may  be  met  with  in  the  lower 
end  of  the  bone  are  the  following  :  (1)  a  fracture 
of  the  shaft  above  the  condyles;  (2)  a  separation 
of  the  lower  epiphysis ;  (3)  a  fracture  separating 
either  the  outer  or  inner  condyle ;  (4)  a  T-shaped 
fracture,  i.e.  a  transverse  fracture  above  the  con- 
dyles with  a  vertical  one  between  those  processes. 
These  lesions  are,  as  a  rule,  due  to  well-localized 
direct  violence.  Fractures  Nos.  1  and  4  may  be 
produced  by  indirect  violence,  as  by  a  fall  upon 
the  feet  from  a  height.  Sir  Henry  Morris  states 
that  lateral  flexion,  or  force  applied  in  a  lateral 
direction,  is  best  calculated  to  produce  a  separa- 
tion of  the  epiphysis.  Hamilton  reports  a  strange 
case  in  a  man  aged  21,  whose  outer  condyle  was 
fractured  by  a  twist  of  the  leg  which  happened 
while  he  was  undressing  himself  to  bathe.  The 
only  fracture  that  requires  special  notice  in  this 


., 


572  THE    LOWEft    EXTREMITY  LChai 

place  is  the  fracture  of  the  shaft  just  above  the 
condyles.  The  lesion  is  situated  generally  about 
2  inches  above  the  line  of  the  epiphysis,  and  corre- 
sponds to  the  spot  where  the  compact  shaft  joins 
the  softer  and  more  cancellous  tissue  of  the  lower 
end  of  the  bone.  It  is  near  the  place,  also,  where 
the  femoral  artery  crosses  the  bone  to  reach  the 
ham,  and  it  has  thus  happened  that  the  vessel 
has  been  wounded  by  splinters  in  this  particular 
injury.  The  fracture  is  usually  oblique,  from  be- 
hind downwards  and  forwards.  The  lower  frag- 
ment will  be  drawn  upwards  by  the  same  muscles 
that  produce  shortening  in  other  fractures  of  the 
shaft  (p.  544),  and  its  sharp  upper  end  is  very 
apt  to  be  pulled  forcibly  into  the  popliteal  space 
by  the  gastrocnemius  muscle.  This  latter  displace- 
ment is  difficult  to  remedy.  If  the  limb  be  ex- 
tended, the  fragment  is  only  drawn  the  more  into 
the  ham,  and  it  is  therefore  possible  for  the  limb 
to  appear  straight  and  yet  have  the  knee-joint 
much  bent.  In  several  cases  of  this  injury  I 
divided  the  tendo  Achillis,  and  then  placed  the 
limb  upon  a  straight  splint,  following  a  practice 
suggested  by  Mr.  Bryant.  The  effect  upon  the 
position  of  the  fragments  was  in  each  case  very 
good  (Brit.  Med.  Journ.,  1883).  The  lower  frag- 
ment of  the  femur  may  be  replaced  by  completely 
flexing  the  leg  on  the  thigh.  (Hutchinson  and 
Barnard.) 

The  upper  end  of  the  tibia  is  sometimes  the 
seat  of  fracture,  although  of  all  parts  of  this 
bone  the  upper  third  is  the  part  least  often 
broken.  One  or  other  of  the  tuberosities  may  be 
broken  off,  or  there  may  be  a  transverse  or  oblique 
fracture  of  the  upper  end  of  the  shaft  associated 
with  a  vertical  one  running  up  into  the  joint  be- 
tween the  two  tuberosities.  Such  accidents  are  the 
result,  in  nearly  every  instance,  of  great  direct 
violence.  Madame  Lachapelle  reports  a  case  of 
separation  of  the  upper  epiphysis  of  the  tibia 
caused  by  traction  during  parturition  ;  but  I  am 
not  aware  of  any  reported  case  of  separation  of 


XXIII1  EXCISION    OF    KNEE-JOINT  573 

this  epiphysis  due  to  violence  or  under  circum- 
stances other  than  this.  Mr.  Makins  reports 
three  cases  of  separation  of  the  anterior  tuber- 
osity in  adolescents.  It  is  usually  ossified  by  an 
extension  from  the  epiphyseal  centre  for  the  upper 
extremity  of  the  tibia,  but  may  have  a  separate 
centre  (Schlatter). 

The  spongy  tissue  in  the  head  of  this  bone  and 
in  the  lower  end  of  the  femur  is,  par  excellence, 
the  favourite  seat  for  myeloid  sarcoma. 

In  excising  the  knee-joint  through  an  incision 
commencing  at  the  back  of  one  condyle,  and 
continued  across  the  joint,  above  the  insertion  of 
the  ligamentum  patellae,  to  the  back  of  the  other 
condyle,  the  following  structures  are  divided  : 
Skin,  fascia,  patellar  plexus  of  nerves  (formed 
by  the  middle  and  internal  cutaneous  and  the 
patellar  branch  of  the  long  saphenous),  bursa 
patellae,  anterior  part  of  the  capsule,  ligamen- 
tum patellae,  synovial  membrane,  lateral  and 
crucial  ligaments,  the  superior  and  inferior  ar- 
ticular arteries,  the  anastomotica  magna,  and 
the  anterior  tibial   recurrent  vessels. 

The  incision  over  the  inner^  condyle  need  not 
be  made  so  far  back  as  to  divide  the  internal 
saphenous  vein  and  nerve.  In  sawing  the  femur 
it  is  most  important  that  the  exact  inclination 
of  the  joint  surface  of  the  bone  be  reproduced. 
If  improperly  sawn,  the  patient  would  be  bow- 
legged  or  knock-kneed.  The  rule,  therefore,  is 
that  the  saw  be  applied  parallel  to  the  articular 
surface  and  perpendicular  to  the  shaft. 

In  young  subjects  care  must  be  taken  that  the 
saw-cuts  do  not  pass  beyond  the  epiphyseal  line. 
The  upper  limit  of  the  femoral  epiphysis  will  be 
represented  by  a  horizontal  line  drawn  across  the 
bone  at  the  level  of  the  tubercle  for  the  adductor 
magnus  (Fig.  118).  %  If  the  whole  of  the  trochlear 
surface  be  removed  in  the  excision  the  whole  of  the 
epiphysis  will  have  been  taken  away.  A  single 
nucleus  appears  in  this  epiphysis  shortly  before 
birth,    and   joins   the   shaft   about  the   twentieth 


574 


THE    LOWER    EXTREMITY 


[Chap. 


year.  The  limits  to  the  tibial  epiphysis  are  repre- 
sented behind  and  at  the  sides  by  a  horizontal  line 
that  just  marks  off  the  tuberosities.  It  includes, 
therefore,  the  depression  for  the  insertion  of  the 
semimembranosus,  and  also  the  facet  for  the  fibula. 
In  front  the  epiphyseal  line  slopes  downwards  on 


SUBCRUREAL     BURSA 


Joint    Cavity 


Liq.   Mucos. 


Subpatel.  Bursa 


Epiphyseal  Lines 


Fig.  118.  — Epiphyseal  lines  in  the  neighbourhood  of  the 
knee-joint  and  their  relationship  to  the  synovial  mem- 
brane.    (After  Allen  Thomson.) 


either  side  to  a  point  on  the  upper  end  of  the  shin, 
so  as  to  enclose  the  whole  of  the  tubercle  of  the 
tibia  (Fig.  118).  The  centre  joins  the  main  bone  at 
the  twenty-first  or  twenty-second  year.  The  popli- 
teal artery  runs  some  risk  of  being  wounded  in 
excision  of  the  joint.  The  vessel  is  separated  by 
some  little  distance  from  the  popliteal  surface  of 


XXIII]     AMPUTATION  THROUGH  KNEE-JOINT    575 

the  femur  (Fig.  117),  but  is  in  very  close  relation 
to  the  tibia,  the  posterior  ligament  alone  inter- 
vening at  the  upper  level  of  the  bone.  It  thus 
happens  that  the  risk  of  wounding  the  artery  is 
greater  when  the  tibia  is  sawn  than  when  the 
lower  part  of  the  femur  is  being  removed. 

Excision  of  the  knee  is,  to  a  large  extent, 
replaced  by  artHrectomy.  Indeed,  excision  of 
this  joint  carried  out  in  the  complete  manner 
just  described  must  be  classed  as  quite  a  rare 
operation. 

Amputation  through  the  knee-joint.— To  il- 
lustrate the  anatomy  of  the  part  an  amputa- 
tion by  a  single  anterior  flap  may  be  selected. 
The  parts  involved  are  shown  in  Fig.  117. 
In  fashioning  the  anterior  flap  (composed  only 
of  integument),  and  in  opening  the  joint,  the 
patellar  plexus  of  nerves,  the  superficial  branches 
of  the  plexus  of  arteries,  the  ligamentum  pa- 
tellae, and  the  anterior  part  of  the  capsule  will 
be  cut.  Nearer  the  condyles  of  the  femur  the 
anastomotic  and  the  two  superior  articular 
arteries  will  be  divided.  The  long  saphenous  vein 
and  nerve  will  be  divided  at  the  inner  angle  of 
the  flap.  On  the  cut  surface  made  by  the  posterior 
incision  will  be  found  divided  the  sartorius, 
gracilis,  and  semitendinosus,  the  semimembran- 
osus, both  heads  of  the  gastrocnemius,  the  popli- 
teus,  plantaris,  and  biceps.  The  popliteal  vessels, 
the  sural  arteries,  the  short  saphenous  vein,  the 
internal  and  external  popliteal  nerves,  the  ex- 
ternal saphenous  and  the  small  sciatic  nerves  will 
also  be  found  divided  in  the  same  incision. 

The  most  convenient  amputation  at  the  knee- 
joint  is  by  equal  lateral  flaps  (Stephen  Smith's 
operation).  This  operation  has  been  attended  by 
excellent  results,  and  in  actual  practice  the 
method  of  amputation  by  a  single  anterior  flap 
is  but  very  rarely  employed, 


CHAPTER   XXIV 

THE    LEG 

Surface  anatomy. — The  anterior  border  of  the 
tibia  can  be  felt  in  its  entire  length,  forming, 
as  it  does,  the  prominence  of  the  shin.  It  should 
be  remembered  that  this  border  presents  a  some- 
what flexuous  course,  being  curved  outwards  above 
and  inwards  below.  The  broad  internal  surface 
of  the  bone  is  subcutaneous,  and  the  internal 
border  can  be  followed  from  the  tuberosity  to  the 
malleolus.  The  head  of  the  fibula  can  be  dis- 
tinctly made  out,  but  the  upper  half  of  the  shaft 
of  the  bone  is  lost  beneath  the  mass  of  muscle  on 
the  outer  side  of  the  limb.  The  lower  half  of  the 
fibular  shaft  can  be  felt,  and  the  bone  just  above 
the  malleolus  becomes  subcutaneous  in  the  interval 
between  the  peroneus  tertius  and  the  two  other 
peroneal  tendons.  The  fibula  is  situated  so  far 
behind  the  line  of  the  tibia  that  a  knife  thrust 
transversely  through  the  leg  from  the  inner  side 
behind  the  tibia  will  appear  in  front  of  the  fibula 
on  the  outer  side  (Fig.  120).  Between  the  tibia  and 
fibula  the  outline  of  the  tibialis  anticus  muscle 
can  be  well  defined  when  it  is  in  action.  To  its 
outer  side  is  the  less  conspicuous  and  narrower 
eminence  formed  by  the  extensor  communis  digi- 
torum.  In  well-developed  limbs  the  groove  that 
separates  these  two  muscles  is  very  distinct,  and 
forms  the  best  guide  to  the  anterior  tibial  artery. 
In  the  lower  third  of  the  leg  these  muscles  be- 
come tendinous,  and  between  them  the  extensor 
576 


Chap.  XXIV]  THE    LEG  577 

longus  hallucis  can  be  felt  as  it  comes  to  the  sur- 
face. The  long  and  short  peroneal  muscles  can  be 
denned,  and  their  tendons  followed  behind  the 
malleolus.  When  in  active  contraction  the  in- 
terval between  the  two  muscles  is  often  well 
marked.  The  gastrocnemius  muscle  and  the  more 
superficial  parts  of  the  soleus  are  brought  well 
into  view  when  the  body  is  raised  upon  the  toes. 
The  two  heads  of  the  former  muscle  are  then  quite 
conspicuous,  and  it  can  be  seen  that  the  inner  head 
is  the  larger  and  descends  lower  in  the  leg. 

The  popliteal  artery  bifurcates  on  a  level  with 
the  lower  part  of  the  tubercle  of  the  tibia  (Fig.  Ill, 
p.  549).  The  course  of  the  posterior  tibial  vessel  is 
represented  by  a  line  drawn  from  the  middle  of 
the  limb  at  the  lower  part  of  the  ham  to  a  spot 
midway  between  the  inner  malleolus  and  the  pro- 
minence of  the  heel.  The  artery  becomes  superficial 
in  the  lower  fourth  of  the  leg,  where  it  may  be  felt 
pulsating  between  the  tendo  Achillis  and  the  tibia. 
The  peroneal  artery  arises  about  3  inches  below 
the  knee,  follows  the  posterior  surface  of  the 
fibula,  and  ends  behind  the  outer  malleolus.  The 
position  of  the  anterior  tibial  artery  may  be  in- 
dicated by  a  line  drawn  from  a  point  midway 
between  the  outer  tuberosity  of  the  tibia  and  the 
head  of  the  fibula  to  the  centre  of  the  front  of  the 
ankle-joint.  Both  the  saphenous  veins  can  often 
be  made  out  in  the  leg.  The  inner  or  larger  vein 
passes  in  front  of  the  malleolus  and  ascends  just 
behind  the  internal  border  of  the  tibia.  With  it  runs 
the  long  saphenous  nerve.  The  short  saphenous 
vein  lies  behind  the  outer  malleolus,  and,  passing 
up  the  middle  of  the  calf,  ends  at  the  ham.  It  is 
accompanied  by  the  external  saphenous  nerve. 

The  skin  is  somewhat  more  adherent  to  the 
deeper  parts  in  the  leg  than  it  is  in  the  thigh. 
The  difference  in  the  degree  of  this  adhesion  is 
obvious  when  skin-flaps  are  dissected  up  from  the 
two  parts  in  cases  of  amputation.  Over  the  in- 
ternal surface  of  the  tibia  and  the  greater  part 
of  the  shin  the  integument  lies  directly  upon  the 

T 


578  THE    LOWER    EXTREMITY  [Chap. 

periosteum  and  bone,  nothing  intervening  save  a 
scanty  amount  of  subcutaneous  fascia.  Thus  blows 
and  kicks  over  these  parts  of  the  leg  are  apt  to  be 
associated  not  only  with  much  pain  but  also  with 
much  bruising  or  tearing  of  the  integument.  A 
"  graze  on  the  shin  "  is  one  of  the  commonest  of 
lesions,  and  is  produced  by  a  degree  of  violence 
that  upon  a  well-covered  part  would  have  little 
or  no  effect.  It  will  be  understood  that  ulcers  over 
these  feebly  protected  parts  may,  if  they  spread 
in  depth,  readily  expose  the  bone  and  lead  to  some 
disease  of  its  substance,  or  to  at  least  some  inflam- 
mation of  its  periosteum.  Scars  left  by  deep 
ulcers  or  burns  are  also  often  found  to  be  quite 
adherent  to  the  bone. 

The  aponeurosis  of  the  leg  invests  it  like  a 
tightly-drawn  buskin,  being  lacking  only  over  the 
subcutaneous  surfaces  of  the  bones  (Fig.  120).  It  is 
attached  to  the  head  and  the  anterior  and  inner 
borders  of  the  tibia,  the  head  of  the  fibula,  and 
the  two  malleoli.  It  is  continuous  above  with  the 
fascia  lata,  and  below  with  the  fascia  of  the  foot  and 
the  annular  ligaments.  It  is  thicker  in  front  than 
behind,  and  is  especially  thick  at  the  upper  part 
of  the  leg  just  below  the  knee.  Here  the  fascia 
offers  great  resistance  to  the  growth  of  tumours 
springing  from  the  head  of  the  tibia.  From  the 
deep  surface  of  the  aponeurosis  two  septa  pass 
inwards  to  be  attached  to  the  anterior  and  ex- 
ternal borders  of  the  fibula.  They  serve  to  isolate 
the  two  larger  peroneal  muscles  from  the  other 
muscles  of  the  limb,  and  form  a  closed  space  which 
might  become  a  definite  and  well-localized  cavity 
for  pus.  Beneath  the  gastrocnemius  and  soleus  a 
layer  of  fascia  extends  between  the  two  bones  and 
covers  in  the  deep  layer  of  muscles.  It  is  thin 
above  but  denser  below,  and  would  have  some  in- 
fluence in  directing  the  progress  of  a  deep  abscess. 

In  the  upper  third  of  the  leg  there  is  a  septum 
between  the  tibialis  anticus  and  extensor  com- 
munis ^  digitorum,  which  must  be  found  in  the 
operation    for   ligaturing   the   upper   part  of  the 


XXIV]  VESSELS    OF   THE    LEG  579 

anterior  tibial  artery.  I  have  never  had  the  good 
fortune  to  see  the  very  distinct  "  white  line  "  that 
many  text-books  describe  as  indicating  the  posi- 
tion of  this  septum. 

In  the  substance  of  the  soleus  muscle  there  is 
a  tendinous  expansion  connected  with  the  inner 
border  of  the  tibia.  In  cutting  through  the  soleus 
to  apply  a  ligature  to  the  posterior  tibial  artery, 
this  intersection  may  be  mistaken  for  the  aponeu- 
rosis on  the  deep  surface  of  the  muscle. 

Several  cases  are  reported  of  rupture  of  some 
part  of  the  gastrocnemius  muscle  during  violent 
exertion.  The  tendo  Achillis  has  been  ruptured 
in  like  circumstances.  This  accident  befell  the 
celebrated  John  Hunter  when  dancing.  It  is 
said  that  the  plantaris  tendon  is  also  not  in- 
frequently torn  across,  producing  a  sudden  sharp 
pain  in  the  calf  during  exertion,  to  which  the 
French  give  the  name  "coapde  fouet." 

Vessels. — The  large  arteries  of  the  leg,  being 
all  in  close  proximity  to  the  bones,  are  apt  to 
be  injured  by  sharp  fragments  in  fractures  of 
the  limb.  This  especially  applies  to  the  peroneal 
artery,  which  runs  along  the  fibula  in  a  fibrous 
canal,  and  is  in  considerable  risk  of  being 
wounded  in  fractures  about  the  middle  of  that 
bone.  It  is  at  the  point  of  bifurcation  of  the 
popliteal  artery  that  emboli  are  peculiarly  apt  to 
lodge.  They  plug  the  vessel  and  practically  block 
'  the  three  main  arteries  of  the  leg.  Gangrene, 
therefore,  not  infrequently  follows  the  occurrence. 
Billroth  states  that  in  all  the  cases  of  gangrene  of 
the  leg  due  to  embolism  that  he  has  met  with,  the 
plug  was  found  situated  at  the  bifurcation  of 
the  popliteal  trunk  ("Clinical  Surgery,"  1881). 
According  to  some  French  surgeons,  aneurysm  of 
the  commencement  of  the  posterior  tibial  artery 
is  more  often  associated  with  gangrene  of  the  leg 
than  is  a  popliteal  aneurysm.  The  reason  they 
assign  is  the  following  :  The  aneurysm  on  the 
former  vessel  not  only  interferes  with  the  passage 
of  the  blood  into  the  posterior  tibial  and  peroneal 


580  THE    LOWER    EXTREMITY  CChap. 

arteries,  but  also  compresses  the  anterior  tibial 
vessel,  and  with  it  the  anterior  tibial  recurrent,  an 
artery  that  is  of  so  great  importance  in  establish- 
ing the  collateral  circulation. 

Varicose  veins  are  more  commonly  met  with 
in  the  leg  than  in  any  other  part  of  the  body, 
save,  perhaps,  in  the  hemorrhoidal  and  spermatic 
veins.  This  depends  upon  the  great  length  of  the 
veins  of  the  lower  limb,  the  large  columns  of  blood 
their  valves  have  to  support,  their  vertical  posi- 
tion, the  liability  of  the  great  trunks  (iliac),  into 
which  they  ultimately  enter,  to  be  compressed, 
and  upon  the  fact  that  the  superficial 
t  veins,  being  outside  the  fascia,  lose  that 

assistance    to    the    circulation    derived 
|  from   muscular   contraction.      From   a 

\  physical    point    of    view    the    vascular 

\      c   system  must  be  regarded  as  a  vertical 
r  column  of  fluid.     The  lower  the  level 

|  f  the  greater  is  the  pressure  on  the  con- 

taining   walls.     The    saphenous    veins 
■  are  thin-walled,  distensible  tubes  situ- 

Fig.  119.  ated  outside  the  rigid-walled  cylinder 
formed  by  the  deep  fascia  of  the  leg 
and  thigh,  low  in  the  body,  where  the  pressure 
from  gravity  is  greatest  (Hill).  The  use  pi 
garters  especially  affects  the  long  saphenous  vein, 
which  lies  close  to  the  bone  at  the  spot  about 
which  these  contracting  bands  are  usually  applied. 
Between  the  two  layers  of  the  muscles  of  the  calf  ' 
Verneuil  describes  a  venous  plexus,  which  he  be- 
lieves to  be  more  often  the  seat  of  varices  than  are 
the  vessels  of  the  surface.  A  varicose  condition 
of  these  deeply  placed  veins  may  explain  the 
"aching  legs"  complained  of  by  those  who  stand 
a  great  deal.  The  intramuscular  veins  are  very 
large.  Callender  showed  that  six  chief  veins 
which  pass  from  the  soleus  muscle  to  enter  into 
the  posterior  tibial  and  peroneal  trunks  have  a 
united  diameter  of  not  less  than  1  inch.  Varix 
would  appear  to  commence  most  often  at  points 
where  the  deep  veins  join  the  superficial  vessels. 


XXIV]  PAIN    TN    THE    LEG  581 

There  is  good  reason  for  this,  for  at  these  points 
three  forces  meet,  the  general  directions  of  which 
are  shown  in  the  annexed  diagram  (Fig.  119). 
There  is  the  weight  of  the  superincumbent  column 
of  blood  (a)  acting  from  above,  the  resistance 
offered  by  the  next  valve  below  the  point  of  entry 
of  the  deep  vein  acting  from  below  (6),  and  the 
force  with  which  the  blood  is  driven  by  the  con- 
tracting muscles  out  of  the  deep  vein  into  the 
superficial  trunk  acting  at  an  angle  to  both  these 
lines  of  force  (c).  Unfortunately  for  the  subjects 
of  varices,  the  two  principal  veins  (the  saphenous) 
are  accompanied  by  sensory  nerves,  and  there  is 
no  doubt  that  much  of  the  pain  incident  to  vari- 
cose veins  in  the  leg  depends  upon  pressure  on 
these  nerves. 

With  reference  to  pain  in  the  leg,  it  must 
be  remembered  that  the  nerves  that  bring  sensa- 
tion to  the  part  arise  at  a  considerable  distance 
from  their  points  of  termination,  and  that  the 
causes  of  pain  in  the  limb  may  be  situated  far 
away  from  the  seat  of  trouble.  Thus,  Sir  B. 
Brodie  mentions  the  case  of  a  gentleman  who  suf- 
fered from  severe  pain  in  the  left  leg,  from  the 
foot  to  the  knee,  in  the  course  of  the  peroneal 
nerve.  No  cause  could  be  found  for  it.  After 
the  patient's  death,  however,  a  large  tumour  was 
found  attached  to  the  lumbar  spine,  which  had 
evidently  compressed  the  left  great  sciatic  nerve. 
It  is  more  difficult  to  offer  an  explanation,  based 
on  anatomical  grounds,  for  cases  such  as  those 
reported  by  Sir  William  Bennett,  where  the  re- 
moval of  a  corn  from  the  sole  of  the  foot  in  one 
instance,  and  a  tumour  from  the  leg  in  another, 
led  to  the  disappearance  of  a  pain  which  was  felt 
in  the  groin. 

There  would  appear  to  be  little  connexion 
between  disease  in  the  rectum  and  a  pain  in  the 
leg,  yet  in  one  case  at  least  that  connexion  was 
marked.  "  Only  recently,"  writes  Mr.  Hilton,  "  I 
saw  a  gentleman  from  South  Wales,  who  was  the 
subject  of  stricture  of  the  rectum  from  malignant 


682  THE    LOWER    EXTREMITY  [Chap. 

disease.  He  suffered  pain  in  the  knee-joint  and  in 
the  back  part  of  the  leg.  This  led  me  to  suspect 
— what  really  turned  out,  upon  careful  examina- 
tion, to  be  the  case — that  a  large  mass  of  cancer 
was  involving  the  nerves  on  the  anterior  part  of 
the  sacrum,  and  also,  no  doubt,  the  obturator 
nerve/' 

Dr.  Ralfe  mentions  cases  of  renal  calculus 
attended  by  severe  pain  in  the  sole  of  the  foot, 
and  I  have  met  with  many  instances  of  this  as- 
sociation, the  pain  being  most  commonly  in  the 
heel. 

Fractures  of  the  leg-.— Of  the  bones  of  the 
leg  the  tibia  and  fibula  are  more  often  broken 
together  than  singly,  and  of  separate  bones  the 
fibula  is  more  often  fractured  than  is  the  larger 
bone. 

1.  The  tibia  and  fibula. — As  regards  the  re- 
sistance it  offers  to  violence  the  fibula  presents 
about  the  same  degree  of  strength  in  all  its  parts, 
save  at  the  malleolus  and  at  its  upper  extremity. 
Its  great  length  and  the  manner  of  its  attachment 
to  the  tibia  (its  two  ends  being  fixed  and  its  main 
part  being  unsupported)  render  it  a  slender  bone, 
and  but  for  the  efficient  protection  it  derives  from 
the  thick  pad  of  muscles  that  surrounds  it,  it 
would  no  doubt  be  very  frequently  broken.  This 
is  all  the  more  likely  to  be  the  case,  since  the  bone 
is  placed  upon  the  more  exposed  aspect  of  the 
limb. 

The  shaft  of  the  tibia  presents  various  degrees 
of  strength,  according  as  we  regard  its  upper, 
middle,  or  lower  third.  According  to  Dr.  Leriche, 
the  average  transverse  diameter  of  the  adult 
tibia  just  below  the  tuberosities  is  a  little  over 
If  inches.  The  transverse  diameter  at  the  base  of 
the  malleolus  is  a  little  less  than  if  inches,  and 
that  of  the  narrowest  part  of  the  bone  is  a  little 
more  than  1  inch.  This  narrow  part  is  at  the 
junction  of  the  lower  with  the  middle  third  of  the 
shaft,  and  is  the  weakest  point  in  the  bone. 

The  relation  of  the  compact  to  the  cancellous 


XXIVJ  FRACTURES    OF    THE    LEG  583 

tissue  is  about  the  same  in  all  parts  of  the  shaft; 
but,  according  to  MM.  Fayel  and  Duret,  the 
spongy  tissue  is  arranged  in  two  independent  ver- 
tical columns,  one  occupying  the  upper  two-thirds 
and  the  other  the  lower  third  of  the  bone.  The 
minimum  of  resistance  (these  authors  assert)  is 
at  the  point  where  these  two  systems  meet.  Thus 
it  happens  that  the  most  common  spot  for  a  frac- 
ture of  the  tibia  is  at  the  junction  of  the  middle 
with  the  lower  third  of  the  shaft.  It  is  here  that 
the  bone  yields  when  broken  by  indirect  violence, 
while  the  lesions  depending  upon  direct  violence 
may  be  at  any  part  of  the  shaft.  Owing  to  the 
thin  covering  of  soft  parts,  and  the  slight  barrier 
interposed  between  the  fracturing  force  and  the 
bone,  it  comes  to  pass  that  fractures  of  the  leg  are 
more  often  compound  and  comminuted  than  are 
those  of  any  other  bones  of  the  extremities.  If  the 
fracture  be  oblique,  as  is  commonly  the  case  when 
the  violence  is  indirectly  applied,  the  line  of 
breakage  usually  extends  from  behind,  down- 
wards, forwards,  and  a  little  inwards.  The  lower 
fragment,  with  the  foot,  is  drawn  up  behind  the 
rest  of  the  bone  by  the  muscles  of  the  calf,  and  is 
usually  displaced  also  outwards  by  the  obliquity 
of  the  fracture  line.  Often  the  lower  fragment  is 
slightly  rotated  outwards  by  the  rolling  over  of 
the  foot,  a  rotation  produced  by  the  simple  weight 
of  the  limb.  If  the  fracture  be  transverse  there 
may  be  little  or  no  displacement.  The  fibula  is 
usually  broken  at  a  higher  level  than  the  tibia, 
and  its  lower  fragment  follows,  of  course,  with 
absolute  precision  the  corresponding  fragment  of 
the  larger  bone.  A  remarkable  spiral  fracture 
(fracture  helicoide),  involving  the  lower  third  of 
the^  tibia,  has  been  described  by  French  surgeons. 
It  is  associated  with  a  more  or  less  vertical  fissure 
that  involves  the  ankle-joint,  and  with  a  fracture 
of  the  fibula  high  up.  MM.  Leriche  and  Tillaux 
have  shown  that  this  injury  is  due  to  torsion, 
especially  to  some  twisting  of  the  leg  while  the 
foot  is  fixed. 


584 


THE    LOWER    EXTREMITY 


[Chap. 


2.  The  fibula  alone.— Fractures  of  this  bone  in 
its  lower  fourth  are  usually  due  to  indirect  vio- 
lence, and  will  be  dealt  with  in  connexion  with 
the  ankle-joint.  When  it  is  broken  in  any  other 
part  the  fracturing  force  is  usually  directly  ap- 
plied, the  lesion  transverse,  and  the  displacement 
insignificant,  or  scarcely  obvious.  The  tibia  acts 
as  an  efficient  splint. 


Peron.  Lonq. 


Ant.  Tib.  Art. 


Peron.  Art. 
Flex.  Long.  Hall. 


Post.  Tia   N. 


Gastrocnem. 


Fig.   120. — Section  across   the  leg  at  the  junction  of  the 
upper  and  middle  thirds.      (After  Braune.) 


3.  The  tibia  alone.  —  The  malleolus  may  be 
broken  by  a  blow,  or  the  lower  epiphysis  sepa- 
rated. The  latter  comprises  the  whole  of  the  inner 
malleolus  and  the  facet  with  which  the  fibula 
articulates.  It  joins  the  shaft  during  the  eigh- 
teenth or  nineteenth  year.  Fractures  of  the  tibia 
alone  are  nearly  always  due  to  direct  violence,  and 
whilst  most  common  in  the  lower  third  of  the  bone, 
become  more  rare  as  the  knee  is  approached. 
When  transverse  there  may  be  no  visible  displace- 
ment, the  fibula  acting  as  a  splint.   Thus,  Sir  Henry 


XXIV] 


FRACTURE    OF    THE    TIBIA 


585 


Morris  mentions  the  case  of  a  woman  who  walked 
into  and  out  of  a  hospital  with  a  transverse  frac- 
ture of  the  tibia  that  was  not  detected  on  examina- 
tion, and  was  not  indeed  discovered  until  two  days 
after  the  accident.  When  the  fracture  is  just 
above  the  ankle  the  lower  fragment  may  be  moved 
in  whatever  direction  the  foot  is  forced,  such  dis- 


Fig.    121. — Transverse   section   through   the    lower    third 
of  the  leg.      {Br mine.) 

a,  Tibialis  anticus  ;  b,  extensor  longus  hallucis  ;  e,  extensor  communis 
digitorum  ;  d,  peroneus  brevis  ;  e,  peroneus  longus  ;  /,  tibialis 
posticus ;  r/,  flexor  longus  digitorum  ;  h,  flexor  longus  ballucis  ; 
i,  gastrocnemius  and  soleus  ;  j,  short  saphenous  nerve  and  vein  ; 
k,  anterior  tibial  vessels  and  nerve  ;  Z,  peroneal  vessels  ;  TO,  pos- 
terior tibial  vessels  and  nerve  ;  n,  musculo-cutaneous  nerve. 


placement  being  resisted  and  limited  by  the  in- 
ferior tibio-fibular  ligaments. 

In  rickets  the  tibia  is,  of  all  the  bones  of  the 
extremities,  the  one  that  most  frequently  becomes 
bent.  It  yields  at  its  weakest  part  (the  lower 
third),  and  there  the  bone  will  be  found  to  have 
developed  a  curve  forwards  and  a  little  outwards. 

Amputation  of  the  leg  at  the  junction  of  the 
upper  with  the  middle  third  by  unequal  antero- 


586  THE    LOWER    EXTREMITY       [Chap.  XXIV 

posterior  flaps  may  be  taken  as  an  example  {set  Fig. 
120).  In  the  anterior  flap  the  following  structures 
would  be  cut  :  Skin,  cutaneous  nerves,  fascia, 
tibialis  m  anticus,  extensor  communis  digitorum 
and  a  little  of  the  extensor  proprius  hallucis,  the 
peroneus  longus  and  a  small  part  of  the  upper 
extremity  of  the  peroneus  brevis,  the  anterior 
tibial  vessels  and  nerve,  and  the  musculo- 
cutaneous nerve.  In  the  posterior  flap  the  follow- 
ing would  be  the  parts  divided  :  Skin,  external 
and  internal  saphenous  veins  and  nerves,  fascia, 
gastrocnemius,  plantaris,  soleus,  tibialis  posticus, 
flexor  longus  digitorum,  a  little  of  the  upper  end 
of  the  flexor  longus  hallucis,  the  posterior  tibial 
vessels  and  nerve,  and  the  peroneal  vessels. 

In  Fig.  121  is  shown  a  transverse  section  of  the 
leg  at  the  lower  third,  from  which  can  be  gathered 
an  idea  of  the  number  and  position  of  the  parts 
cut  in  amputations  through  that  part. 

An  excellent  method  of  amputation  at  the 
upper  part  of  the  leg  is  by  a  single  external  flap 
containing  the  anterior  tibial  artery  in  its  entire 
length. 


CHAPTER    XXV 

THE    ANKLE    AND    THE   FOOT 

Surface  anatomy.  Bony  points. —The  outlines 
of  the  two  malleoli  can  be  very  distinctly  denned. 
The  external  is  somewhat  the  less  prominent, 
descends  lower,  and  lies  farther  back  than  the 
internal  process.  The  tip  of  the  outer  malleolus 
is  about  i  an  inch  behind  and  below  the  tip  of 
the  corresponding  bony  prominence.  The  antero- 
posterior diameter,  however,  of  the  internal  mal- 
leolus is  such  that  its  posterior  border  is  on  a 
level  with  that  of  the  outer  process  behind. 

On  the  dorsum  of  the  foot  the  individual  tarsal 
bones  are  not  to  be  distinguished,  although  the 
astragalus  forms  a  distinct  projection  upon  that 
surface  when  the  foot  is  inverted. 

On  the  inner  side  of  the  foot  the  tuberosity  of 
the  os  calcis  may  be  felt  most  posteriorly.  In 
front  of  it,  and  about  1  inch  vertically  below  the 
inner  malleolus,  is  the  projection  of  the  sustenta- 
culum tali.  About  lj  inches  in  front  of  the  mal- 
leolus the  tuberosity  of  the  scaphoid  can  be  dis- 
tinctly made  out  (Fig.  125,  p.  611).  In  the  interval 
between  it  and  the  last-named  process  lie  the 
inferior  calcaneo-scaphoid  ligament,  and  the  ten- 
don of  the  tibialis  posticus.  Farther  towards  the 
front  of  the  foot  can  be  felt  the  ridge  formed  by 
the  base  of  the  first  metatarsal  bone,  and  between 
it  and  the  scaphoid  tubercle  lies  the  inner  cunei- 
form bone.  Lastly,  the  shaft  of  the  first  meta- 
tarsal bone,  its  expanded  head,  and  the  sesamoid 
587 


588  THE    LOWER    EXTREMITY  [Chap. 

bones  that  lie  on  the  plantar  aspect  of  the  meta- 
tarsal phalangeal  joint  can  be  more  or  less  dis- 
tinctly denned.  On  the  outer  side  of  the  foot  the 
external  surface  of  the  os  calcis  is  subcutaneous  in 
nearly  the  whole  of  its  extent.  Less  than  1  inch 
below  and  in  front  of  the  malleolus  is  the  peroneal 
tubercle,  with  the  short  peroneal  tendon  above  it 
and  the  long  one  below  it.  Some  2j  inches  from 
the  outer  malleolus  the  projection  of  the  base  of 
the  fifth  metatarsal  bone  is  very  evident,  and  ex- 
tending for  an  inch  or  so  behind  it  lies  the  cuboid 
bone. 

Joint  lines.— The  ankle-joint  lies  about  on  a 
level  with  a  point  J  an  inch  above  the  tip  of  the 
inner  malleolus.  Immediately  behind  the  tubercle 
of  the  scaphoid  is  the  astragalo-scaphoid  articula- 
tion, and  a  line  drawn  transversely  across  the 
dorsum  of  the  foot,  just  behind  the  process,  very 
fairly  corresponds  to  the  mid-tarsal  joint  (the 
joint  compounded  of  the  astragalo-scaphoid  and 
calcaneo-cuboid  articulations). 

If  the  latter  articulation  be  approached  from 
the  outer  side  it  will  lie  opposite  a  point  midway 
between  the  outer  malleolus  and  the  prominent 
base  of  the  fifth  metatarsal  bone. 

The  lines  of  the  articulations  between  the  first 
and  fifth  metatarsal  bones  and  the  inner  cunei- 
form and  the  cuboid  respectively  are  easily  indi- 
cated, being  placed  just  behind  the  bases  of  the 
former  bones.  The  metatarso-phalangeal  articula- 
tions are  situated  about  1  inch  behind  the  webs  of 
the  corresponding  toes.  The  proximal  phalanx 
and  part  of  the  middle  are  buried  in  the  web. 

Tendons. — The  tendo  Achillis  stands  out  very 
conspicuously  at  the  back  of  the  ankle,  and  be- 
tween it  and  the  malleoli  are  two  hollows  which 
are  evident  in  even  obese  individuals.  Over  the 
front  of  the  ankle  the  tendons  of  the  extensor 
muscles  are  readily  to  be  distinguished,  especially 
when  the  joint  is  flexed.  From  within  outwards 
they  are  :  the  tendons  of  the  tibialis  anticus,  ex- 
tensor longus  hajlucis,  extensor  longus  digitorum, 


XXV]  ANKLE    AND    FOOT  580 

and  peroneus  tertius.  Beneath  the  tendons  of  the 
extensor  of  the  toes,  and  on  the  outer  part  of 
the  dorsum  of  the  foot,  the  prominent  fleshy  mass 
formed  by  the  extensor  brevis  digitorum  can  be 
felt  and,  when  in  action,  seen.  Above  and  behind 
the  inner  malleolus  the  tendons  of  the  tibialis 
posticus  and  flexor  longus  digitorum  can  be  dis- 
cerned, the  former  lying  nearer  to  the  bone. 
Nearer  to  the  middle  line  runs  the  flexor  longus 
hallucis.  Behind  the  outer  malleolus  the  long  and 
short  peroneal  tendons  can  be  felt,  lying  close  to 
the  edge  of  the  fibula,  the  tendon  of  the  smaller 
muscle  being  the  closer  to  it. 

In  the  middle  of  the  sole  of  the  foot  the  resist- 
ing plantar  fascia  can  be  felt,  and  some  of  its 
processes  made  out  when  the  toes  are  drawn  up  by 
the  extensors.  The  fleshy  mass  on  the  inner 
margin  of  the  foot  is  formed  by  the  abductor  and 
flexor  brevis  hallucis;  that  on  the  outer  side  by 
the  abductor  and  flexor  brevis  minimi  digiti. 

Vessels. — The  anterior  tibial  artery  and  nerve 
are  placed  opposite  the  ankle-joint,  between  the 
tendons  of  the  extensor  proprius  hallucis  and 
longus  digitorum.  The  dorsal  artery  runs  from 
the  middle  of  the  ankle  to  the  interval  between 
the  bases  of  the  first  and  second  metatarsal  bones. 
It  may  be  felt  pulsating  against  the  bones  along 
the  outer  side  of  the  extensor  proprius  hallucis 
tendon,  which  is  the  readiest  guide  to  it.  The 
plantar  arteries  start  from  a  point  midway  be- 
tween the  tip  of  the  malleolus  internus  and  the 
centre  of  the  convexity  of  the  heel.  The  internal 
vessel  follows  a  line  drawn  from  this  point  to  the 
middle  of  the  under  surface  of  the  great  toe.  The 
external  vessel  crosses  the  sole  obliquely  to  within 
a  thumb' s-breadth  of  the  base  of  the  fifth  meta- 
tarsal bone.  From  thence  it  turns  more  trans- 
versely across  the  foot,  running  inwards  over  the 
bases  of  the  metatarsal  bones  to  inosculate  with 
the  dorsalis  pedis  artery  at  the  back  of  the  first 
interosseous  space.  On  the  dorsum  of  the  foot  the 
subcutaneous  veins  may  be  seen  forming  an  arch 


500  THE    LOWER    EXTREMITY  [Chap. 

convex  towards  the  toes,  and  from  the  ends  of  the 
arch  vessels  may  be  followed  into  the  internal  and 
external  saphenous  veins. 

The  skin  about  the  ankle  and  over  the  dor- 
sum of  the  foot  is  thin  and  but  loosely  attached 
to  the  subjacent  parts.  It  becomes  readily  ex- 
coriated, as  is  frequently  the  case  where  splints 
or  instruments  have  been  improperly  applied. 
Since  the  skin  over  the  malleoli  lies  directly 
upon  the  bone,  while  that  covering  the  dorsum 
of  the  foot  is  but  slightly  separated  from  the 
bones  of  the  tarsus,  it  follows  that  the  integu- 
ments in  this  region  are  readily  contused,  and 
may  suffer  gangrene  from  an  amount  of  pressure 
that  would  cause  but  little  trouble  in  other  parts. 
Over  the  sole  the  integument  is  dense  and  thick  in 
all  those  parts  that  come  in  contact  with  the 
ground.  In  the  normal  foot,  the  heel,  the  outer 
margin  of  the  foot,  and  the  line  of  metatarso- 
phalangeal joints  are  in  contact  with  the  ground 
when  the  sole  is  placed  flat  upon  it  (Fig.  126, 
p.   612). 

The  subcutaneous  tissue  about  the  ankle  and 
foot  varies  greatly  both  in  quantity  and  charac- 
ter. Over  the  front  of  the  ankle  and  dorsum  of 
the  foot  it  is  very  lax,  free  from  fat,  and  is  the 
first  part  to  be  infiltrated  in  general  dropsy  of 
the  body.  On  the  sole  the  subcutaneous  tissue  is 
dense,  firm,  and  studded  with  pellets  of  fat.  It 
is  |  of  an  inch  thick  over  the  heel. 

The  integuments  of  the  foot  are  well  supplied 
with  nerves,  being  furnished  with  branches  from 
no  less  than  six  nerve  trunks,  the  musculocutane- 
ous, the  anterior  tibial,  the  two  saphenous,  and 
the  external  and  internal  plantar.  Many  Paci- 
nian bodies  are  found  upon  these  cutaneous 
branches,  and  end-bulbs  are  met  with  in  the  skin 
on  the  sole.  The  integuments  of  the  foot  respond 
acutely  to  sensations  of  pain,  of  pressure,  of  tem- 
perature, and  to  certain  unwonted  forms  of  tac- 
tile impression,  such  as  tickling.  Tactile  sensi- 
bility, however,  as  measured  by  the  sesthesiometer, 


XXV]  ANKLE    AND    FOOT  591 

is  not  acute,  the  dorsum  of  the  foot  showing,  in 
regard  to  this  matter,  no  more  sensitiveness  than 
does  the  skin  of  the  buttock. 

Over  the  "  tread  of  the  foot,"  and  especially 
under  the  ball  of  the  great  toe,  the  peculiar 
affection  known  as  "perforating  ulcer"  is  most 
commonly  met  with.  This  ulcer  occurs  as  an 
occasional  symptom  in  certain  nerve  maladies, 
and  particularly  in  locomotor  ataxy. 

Fasciae  of  the  foot  and  the  tendons 
about  the  ankle. — The  fasciae  on  the  dorsum 
occur  in  two  layers,  a  superficial  one  that  is  con- 
tinued from  the  anterior  annular  ligament,  and  a 
deeper  placed  over  the  extensor  brevis  and  inter- 
ossei  muscles.  These  membranes  are  both  thin  and 
insignificant,  and  exercise  no  influence  from  a 
surgical  point  of  view.  The  plantar  fascia  is 
divided  into  three  parts,  a  central  or  main  por- 
tion which  is  extremely  dense  and  powerful,  and 
two  lateral  expansions  which  are  thin  and  surgi- 
cally insignificant.  The  outer  of  the  two  lateral 
portions  is,  however,  of  some  substance,  and  forms 
a  very  thick  band  between  the  os  calcis  and  fifth 
metatarsal  bone,  that  may  become  rigidly  con- 
tracted in  some  forms  of  talipes.  The  central  ex- 
pansion assists  greatly  in  supporting  the  antero- 
posterior arch  of  the  foot,  which  it  tends  to  main- 
tain in  the  manner  that  the  bowstring  maintains 
the  arch  of  the  bow. 

The  sinking  of  the  arch  that  occurs  in  "  flat 
foot y  is  associated  with  marked  yielding  of  this 
fascia.  The  plantar  fascia  is  often  found  much 
contracted  (as  a  rule,  secondarily)  in  certain 
forms  of  club-foot,  such  as  talipes  equinus  and 
congenital  varus.  The  term  "  talipes  cavus  "  is 
applied  to  a  deformity  that  depends  mainly  or 
entirely  upon  a  contraction  of  the  plantar  fascia. 
The  best  place  in  which  to  divide  this  membrane 
is  at  a  spot  about  1  inch  in  front  of  its  attachment 
to  the  os  calcis.  This  is  its  narrowest  part,  and 
the  knife  (which  should  be  introduced  from  the 
inner  side)   will  be  behind  the  external  plantar 


592  THE    LOWER    EXTREMITY  [Chap. 

artery  which  runs  beneath  the  expansion.  An 
abscess  situated  beneath  the  membrane  will  be  very 
closely  bound  down,  and  will  advance  in  any 
direction  other  than  through  the  membrane  itself 
so  as  to  point  in  the  centre  of  the  sole.  Such  deep 
collections  cause  intense  pain,  and  often  much 
destruction,  before  they  are  discharged.  They 
may  open  upon  the  dorsum,  or  may  extend  up 
along  the  tendons  to  the  region  of  the  ankle. 
There  are  certain  foramina  or  spaces  in  the  sub- 
stance of  this  layer  occupied  usually  by  fat; 
through  one  or  more  of  these  an  abscess  will,  in 
exceptional  cases,  extend,  and  then  spread  out  be- 
neath the  integuments.  Such  an  abscess  will  have, 
therefore,  two  cavities  united  by  a  small  hole,  and 
will  form  the  abces  en  bissac  or  en  bouton  de 
chemise  of  the  French.  The  plantar  fascia  divides 
into  slips  near  the  roots  of  the  toes,  and  forms  a 
series  of  arches,  beneath  which  pass  the  tendons, 
vessels,  and  nerves  bound  for  the  digits.  Two 
intermuscular  septa  connected  with  the  membrane 
separate  the  flexor  brevis  digitorum  from  the  ab- 
ductor^  hallucis  on  the  one  side  and  the  abductor 
minimi  digiti  on  the  other.  They  are,  however, 
membranes  of  too  feeble  a  structure  to  affect  much 
the  progress  of  a  deep  plantar  abscess. 

The  anterior  annular  ligament  is  divided  into 
two  parts;  an  upper  band  in  front  of  the  tibia 
and  fibula,  and  a  lower  band  in  front  of  the 
upper  limits  of  the  tarsus  (Fig.  122).  Beneath 
the  former  there  is  only  one  synovial  sheath,  that 
for  the  tibialis  anticus ;  beneath  the  latter  are 
three  sheaths — one  for  the  peroneus  tertius  and 
extensor  communis,  one  for  the  extensor  proprius 
pollicis,   and  a  third  for  the  tibialis  anticus. 

According  to  Holden,  there  is  often  a  large 
irregular  bursa  between  the  tendons  of  the  ex- 
tensor longus  digitorum  and  the  projecting  end 
of  the  astragalus.  This  bursa  sometimes  communi- 
cates with  the  joint  at  the  head  of  the  astragalus. 

Beneath  the  internal  annular  ligament  are 
three    synovial    sheaths    for    the    tendons    of    the 


XXVJ 


ANKLE    AND    FOOT 


593 


tibialis  posticus,  flexor  longus  digitorum,  and 
flexor  longus  hallucis.  Inflammation  involving 
the  sheath  for  the  tibialis  posticus  may  spread  to 


Upper  Ant.  Ann.   Liq. 


Lower  Ant.  Ann.   Liq. 


Peron.  Tertius 


Ext.   Long.    Hall. 


Ext.   Brev.  Hall. 


Fig.  122. — Synovial    sheaths    on   the   extensor   surface   of 
foot  and  ankle.     [Lovell  and  Tanner.) 

the  ankle-joint,  with  which  the  tendon  is  in  close 
relation.  Beneath  the  outer  annular  ligament  is 
the  single  synovial  sheath  for  the  long  and  short 
peroneal  tendons. 

In  severe  sprains  of  the  ankle  not  only  are  the 


594  THE    LOWER    EXTREMITY  [Chap. 

ligaments  about  the  joint  more  or  less  ruptured, 
but  the  various  synovial  sheaths  just  named  are 
apt  to  be  torn  and  filled  with  blood.  The  long 
abiding  trouble  in  the  part  that  often  follows 
severe  sprains  depends  to  a  great  extent  upon 
damage  to  these  sheaths,  and  to  extravasations  of 
blood,  and  subsequently  of  inflammatory  material, 
within  thorn.  These  sheaths  are  more  extensive  than 
they  are  usually  supposed  to  be ;  those  at  the  inner 
side  of  the  ankle  commence  from  1  to  2  inches 
above  the  malleolus,  and  extend  into  the  sole  of 
the  foot  to  a  point  opposite  the  tuberosity  of  the 
scaphoid.  Those  at  the  outer  side  of  the  ankle  are 
even  more  extensive,  that  round  the  peroneus 
longus  extending  to  the  base  of  the  first  meta- 
tarsal, although  occasionally  the  plantar  and  mal- 
leolar parts  may  be  found  completely  separated 
from  each  other  at  the  outer  border  of  the  cuboid. 
From  the  length  of  the  sheaths  it  can  be  readily 
understood  that  the  adhesions  which  follow 
sprains  and  fractures  at  the  ankle  are  very  ex- 
tensive, unless  passive  movements  be  carried  out 
to  prevent  their  formation. 

There  are  few  bursae  of  any  magnitude  about 
the  foot,  save  one  between  the  tendo  Achillis  and 
os  calcis,  and  another  over  the  metatarso-phalan- 
geal  joint  of  the  great  toe.  The  first-named  bursa 
rises  up  about  \  an  inch  above  the  os  calcis,  and 
bulges  out  on  either  side  of  the  tendon.  When  in- 
flamed it  may  produce  symptoms  like  those  of 
ankle-joint  disease,  and  when  suppurating  may 
lead  to  caries  of  the  os  calcis.  The  enlargement  of 
the  bursa  over  the  metatarsophalangeal  joint  of 
the  great  toe  constitutes  a  bunion.  It  lies  in  the 
subcutaneous  tissue  between  the  internal  sesamoid 
and  the  skin,  and  is  not  present  at  birth.  This 
condition  is  generally  brought  about  by  impro- 
perly shaped  boots,  which  force  the  great  toe  out- 
wards, place  it  obliquely  to  the  long  axis  of  the 
foot,  and  render  the  metatarsal  joint  very  promi- 
nent. The  cartilage  over  the  inner  part  of  the 
head  of  the  metatarsal  bone   disappears,   and  a 


XXV]  ANKLE    ANt)    FOOT  505 

communication  between  the  bursa  and  joint  may 
be  set  up.  The  result  of  this  deformity  is  a  great 
weakening  of  the  toe  and  adjacent  part  of  the 
foot,  a  lengthening  of  the  internal  lateral  liga- 
ment of  the  joint,  and  a  displacement  outwards  of 
the  tendon  of  the  extensor  proprius  hallucis. 
Bursae  are  often  developed  over  the  malleoli  in 
tailors,  and  especially  over  the  external  process, 
the  part  most  pressed  upon  when  sitting  cross- 
legged.  In  club-foot,  bursse  are  found  over  any 
points  that  are  exposed  to  undue  pressure. 

The  tendons  about  the  ankle  are  not  infre- 
quently ruptured  by  violence.  Those  that  most 
often  are  so  injured  are  the  tendo  Achillis  and  the 
tendons  of  the  tibialis  posticus,  and  long  and 
short  peroneal  muscles.  The  tendo  Achillis  usually 
breaks  at  a  point  about  lj  inches  above  its  inser- 
tion, where  it  becomes  narrowed  and  its  fibres 
collected   into   a  very   definite  bundle. 

In  some  forms  of  violence  the  synovial  and 
fibrous  sheaths  that  bind  down  a  tendon  may  be 
ruptured  and  it  may  be  allowed  to  become  dis- 
placed. This  has  happened  to  the  tibialis  posticus 
and  peroneal  muscles.  In  each  instance  the  dis- 
located structure  comes  forward  upon  or  in  front 
of  the  malleolus.  No  tendon  in  the  body  is  so 
frequently  displaced  as  is  that  of  the  peroneus 
longus. 

The  tendons  about  the  ankle  are  frequently 
divided  by  operation.  The  tendo  Achillis  is 
usually  cut  about  1  inch  above  its  insertion,  the 
knife  being  entered  from  the  inner  side  to  avoid 
the  posterior  tibial  vessels.  The  tibialis  posticus 
tendon  is,  as  a  rule,  divided  just  above  the  base  of 
the  inner  malleolus.  There  is,  however,  enough 
room  between  the  annular  ligament  and  the  sca- 
phoid bone  to  cut  it  on  the  side  of  the  foot  (Fig. 
125,  p.  611).  The  anterior  tibial  tendon  may  be 
divided  readily  either  in  front  of  the  ankle  or  at 
its  insertion  into  the  internal  cuneiform  bone.  On 
section  of  a  tendon  a  gap  is  felt,  owing  to  retrac- 
tion by  the  muscle.     The  cut  ends  are  still  united 


596  THE   LOWER    EXTREMITY  [Chap. 

by  the  fibrous  tissue  in  which  they  lie,  and  from 
which  they  derive  their  blood  supply.  If  cut 
within  a  sheath  the  synovial  membrane  forms  a 
loose  binding  between  the  cut  ends.  A  fibrous 
band  between  the  cut  ends  is  ultimately  formed 
from  the  effusion  which  fills  the  gap.  The  new 
band  is  firmly  adherent  to  the  sheath  in  which  it 
lies,  and  at  first  will  limit  the  movements  of  the 
tendon. 

Part  of  the  tendon  of  a  sound  muscle  may  be 
yoked  to  that  of  one  which  has  become  paralysed, 
thus  restoring  certain  movements  to  the  foot. 

Blood-vessels. — The  lines  of  the  various  arte- 
ries have  been  already  indicated  (p.  580).  Wounds 
of  the  plantar  arch  are  serious,  on  account  of  the 
depth  at  which  the  external  plantar  artery  lies, 
and  the  impossibility  of  reaching  the  vessel  with- 
out making  a  large  wound  in  the  sole  that  would 
open  up  important  districts  of  connective  tissue 
and  do  damage  to  tendons  and  nerves.  The  arch 
is  formed  by  the  junction  of  the  external  plantar 
artery  with  the  dorsal  artery  of  the  foot,  a  con- 
tinuation of  the  anterior  tibial  vessel.  In  cases, 
however,  of  bleeding  from  the  arch,  ligature  of 
both  the  posterior  and  anterior  tibial  vessels  at  or 
just  above  the  ankle  would  not  necessarily  arrest 
the  haemorrhage.  After  ligature  of  these  vessels 
blood  would  still  be  brought  indirectly  to  the  arch 
by  means  of  the  peroneal  artery.  By  its  anterior 
peroneal  branch  this  vessel  communicates  with  the 
external  malleolar  branch  of  the  anterior  tibial 
artery,  and  with  the  tarsal  branch  of  the  dorsalis 
pedis.  By  its  terminal  branch  it  communicates 
with  the  two  last-named  vessels,  and  also  with  the 
internal  calcaneal  branches  of  the  external  plan- 
tar artery.  As  a  matter  of  practice,  however, 
elevation  of  the  limb,  together  with  pressure  upon 
the  wounded  point  and  compression  of  the  main 
artery,  is  sufficient  to  check  most  haemorrhages 
from  the  plantar  arch. 

The  dorsalis  pedis  artery,  from  its  superficial 
position  and  its  close  contact  with  the  bones  of  the 


XXV]  ANKLE    AND    FOOT  597 

foot,  is  frequently  divided  in  wounds  and  rup- 
tured in  severe  contusions.  The  posterior  tibial 
artery  at  the  ankle  is  well  protected  by  the  pro- 
jecting malleolus,  the  dense  annular  ligament,  and 
the  tendons  that  run  by  its  side. 

The  superficial  veins  of  the  foot,  like  those  of 
the  hand,  are  found  mainly  upon  the  dorsum  of 
the  member.  The  sole,  as  a  part  exposed  to  pres- 
sure, is  singularly  free  from  them.  About  the 
malleoli,  and  especially  about  the  inner  process, 
these  veins  form  a  considerable  plexus.  Hence  it  is 
that  appliances  which  fit  tightly  around  the  anklo 
are  apt  to  produce  oedema  and  pain  in  the  parts 
beyond.  The  dull  pain  in  the  feet  that  is  often 
caused  by  tight  elastic-side  boots  is  probably  due 
to  the  same  cause. 

The  lymphatics  forrn^  a  very  fine  and  elabo- 
rate plexus  in  the  coverings  of  the  sole,  from 
which  vessels  arise  that  reach  the  borders  and  dor- 
sum of  the  foot,  and  principally  the  inner  border. 
The  main  lymph-vessels  of  the  part  are  found 
upon  the  dorsum,  about  the  radicles  of  the  two 
saphenous  veins.  Those  on  the  inner  side  of  the 
foot  are  by  far  the  more  numerous;  they  follow 
pretty  generally  the  course  of  the  internal  saphen- 
ous vein,  and  end  in  the  inguinal  glands.  The 
external  vessels  pass  up  along  the  outer  ankle  and 
outer  side  of  the  leg.  The  bulk  of  them  pass 
obliquely  across  the  ham  to  join  the  inner  set 
above  the  knee ;  others  reach  the  inner  set  bv  cross- 
ing the  front  of  the  tibia,  while  a  few  follow  the 
short  saphenous  vein  and  end  in  the  popliteal 
glands  {see  p.  557). 

The  ankle-joint  is  a  very  powerful  articula- 
tion, its  strength  being  derived  not  only  from  the 
shape  of  its  component  bones,  but  also  from  the 
unyielding  ligaments  and  many  tendons  that  are 
bound  about  it  like  straps.  Of  the  ligaments,  the 
two  lateral  are  very  strong,  and  have  an  extensive 
hold  upon  the  foot.  The  anterior  and  posterior 
are  extremely  thin  and  insignificant,  although  the 
latter  is  supported  by  the  tendon  of  the  flexor 


598  THE    LOWEE    EXTREMITY  [Chap. 

longus  hallucis,  which  crosses  it.  When  effusion 
takes  place  into  the  joint,  it  first  shows  itself  in 
front,  beneath  the  extensor  tendons,  and  just  in 
front  of  the  lateral  ligaments.  This  is  due  to  the 
feebleness  of  the  anterior  ligament  and  the  extent 
and  looseness  of  the  synovial  sac  in  relation  with 
that  structure.  More  extensive  effusions  cause  a 
bulging  behind  through  yielding  of  the  thin  pos- 
terior part  of  the  capsule,  and  fluctuation  can 
then  be  obtained  on  either  side  of  the  tendo 
Achillis.  In  no  ordinary  case  can  fluctuation  be 
detected  distinctly  beneath  the  unyielding  lateral 
ligaments.  Moreover,  the  loose  synovial  sac  of  the 
ankle-joint  extends  both  in  front  and  behind  be- 
yond the  limits  of  the  articulation,  while,  at  the 
sides,  it  is  strictly  limited  to  the  joint  surfaces. 
The  ankle  is  a  perfect  hinge-joint,  and  permits 
only  of  flexion  and  extension.  The  very  slightest 
amount  of  lateral  movement  is  allowed  in  extreme 
extension,  when  the  narrower,  or  hinder,  part  of 
the  astragalus  is  brought  into  contact  with  tne 
widest,  or  anterior,  part  of  the  tibio-fibular  arch. 
When  obvious  lateral  movement  exists  at  the 
ankle,  the  joint  must  be  the  seat  of  either  injury 
or  disease ;  and  it  is  important  not  to  mistake 
the  lateral  movements  permitted  between  certain 
of  the  tarsal  bones  for  movements  at  the  ankle- 
joint.  Dorsi-flexion  is  limited  by  the  posterior 
and  middle  parts  of  the  internal  ligament,  by  the 
posterior  part  of  the  external  ligament,  by  the  pos- 
terior ligament,  and  by  the  contact  of  the  astra- 
galus with  the  tibia.  Plantar  flexion  is  limited 
by  the  anterior^  fibres  of  the  inner  ligament,  the 
anterior  and  middle  parts  of  the  outer  ligament, 
by  the  anterior  part  of  the  capsule,  and  the  con- 
tact of  the  astragalus  with  the  tibia. 

Owing  to  its  exposed  position,  this  joint  is 
very  liable  to  become  inflamed  from  injury  or 
other  external  causes.  When  inflamed,  no  dis- 
tortion is,  as  a  rule,  produced,  the  foot  remaining 
at  right  angles  with  the  leg.  It  would  appear 
that  this  position  is  due  to  the  circumstance  that 


XXVj        DISLOCATIONS    AT    ANKLE-JOINT  599 

the  flexor  and  extensor  muscles  about  balance  one 
another,  and  it  does  not  seem  that  the  capacity  of 
the  joint  is  affected  by  the  posture  of  the  foot. 
The  synovial  cavity  of  the  ankle  is  in  communica- 
tion with  the  inferior  tibio-fibular  articulation. 

In  connexion  with  the  subject  of  "  referred 
pains/'  it  should  be  remembered  that  the  nerves 
supplying  the  ankle-joint  bring  that  articulation 
into  relation  with  the  lumbar  segments  of  the 
spinal  cord  through  the  internal  saphenous,  and 
the  sacral  segments  through  the  anterior  tibial 
nerve. 

Dislocations  at  the  ankle-joint. — The  foot  may 
be  dislocated  at  the  ankle  in  five  directions,  which, 
placed  in  order  of  frequency,  are  :  outwards, 
inwards,  backwards,  forwards,  and  upwards  be- 
tween the  tibia  and  fibula.  These  dislocations 
are  nearly  always  associated  with  fracture  of 
either  the  tibia  or  fibula  or  of  both  bones. 

1.  The  lateral  dislocations :  Outwards,  in- 
wards. These  luxations  differ  somewhat  from 
those  met  with  in  other  joints.  In  the  great 
majority  of  cases  they  consist  of  a  lateral  twisting 
of  the  foot,  of  such  a  kind  that  the  astragalus  is 
rotated  beneath  the  tibio-fibular  arch.  There  is 
no  great  removal  of  the  upper  surface  of  the  astra- 
galus from  that  of  the  tibia,  one  or  other  edge 
of  the  former  bone  being  brought  in  contact  with 
the  horizontal  articular  surface  of  the  latter. 
Although  much  deformity  is  produced,  the  actual 
separation  of  the  foot  from  the  leg  is  not  con- 
siderable. In  some  rare  cases  a  true  lateral  dis- 
location in  the  horizontal  direction  has  been  met 
with. 

These  injuries  are  due  to  sudden  and  violent 
twistings  of  the  foot,  and  are  in  nearly  every  in- 
stance associated  with  fractures  of  the  tibia  or 
fibula.  The  luxation  outwards  is  due  to  forcible 
eversion  of  the  foot,  the  luxation  inwards  to  vio- 
lent inversion. 

It  is  of  interest,  in  the  first  place,  to  note  the 
relation  of  the   fibula  to   injuries  at  the   ankle- 


600 


THE    LOWER    EXTREMITY 


[Chap. 


joint,  especially  as  a  fracture  of  the  lower  end  of 
the  shaft  of  that  bone  may  follow  alike  upon  both 
inversion  and  eversion  of  the  foot.  The  lower  3 
or  4  inches  of  the  fibula  may  be  considered  to  form 
a  lever  of  the  first  kind  (Fig.  123,  a).    The  fulcrum 


Fig,  123. — Diagrams  to  illustrate  the  mechanism  involved 
in  fractures  of  the  lower  end  of  the  fibula. 

A,  Parts  in  normal  position:  a,  tibio-iibular  ligaments;  b,  external 
lateral  ligament ;  c,  internal  lateral  ligament.  B,  Fracture  of 
fibula  due  to  eversion  of  foot.  C,  Fracture  of  fibula  due  to  inver- 
sion of  foot. 

is  at  the  inferior  tibio-fibular  articulation,  one 
arm  of  the  lever  is  the  malleolus  below  that  joint, 
while  the  other  arm  may  be  regarded  as  formed 
by  the  lower  2  or  3  inches  of  the  shaft  of  the  bone. 
Now  the  lower  ends  of  the  tibia  and  fibula  are 
bound  together  by  verv  powerful  ligaments,  viz. 
the  anterior  and  posterior  tibio-fibular,  the  trans- 


XXV]        DISLOCATIONS    AT    ANKLE-JOINT  GDI 

verse,  and  the  inferior  interosseous.  I  would  ven- 
ture to  insist  particularly  that  in  no  ordinary 
lesion  about  the  ankle,  whether  fracture  or  dis- 
location, do  these  ligaments  give  way.  If  they 
should  yield,  then  an  anomalous  form  of  fracture 
or  luxation  would  be  produced.  In  forcible  eversion 
of  the  foot,  the  internal  lateral  ligament  becomes 
stretched  and  tears,  the  astragalus  is  rotated 
laterally  beneath  the  tibio-fibular  arch  and  is 
brought  into  violent  contact  with  the  end  of  the 
outer  malleolus.  This  process  is  pushed  outwards, 
and  acts  as  one  end  of  a  lever.  The  fulcrum  is 
secured  by  the  unyielding  tibio-fibular  ligaments, 
and  the  fibula  breaks  at  the  other  end  of  the  lever, 
a  point  some  2  or  3  inches  above  the  end  of  the 
bone  (Fig.  123,  b).  In  forcible  inversion  of  the 
foot,  the  astragalus  undergoes  a  little  lateral  rota- 
,  tion  in  the  opposite  direction ;  the  external  lateral 
ligament  is  greatly  stretched,  and  tends  to  drag 
the  end  of  the  outer  malleolus  inwards.  If  the 
ligament  yields,  the  case  will  probably  end  as  a 
sprained  ankle,  or  pass  on  to  a  dislocation  in- 
wards of  the  foot.  But  if  it  remains  firm,  the  end 
of  the  fibular  lever  (the  tip  of  the  malleolus)  is 
drawn  towards  the  middle  line,  the  fulcrum  is 
secured  by  the  tibio-fibular  ligaments,  and  the 
shaft  breaks  at  the  other  end  of  the  lever,  some 
few  inches  above  the  end  of  the  bone  (Fig.  123,  c). 
It  will  be  seen  that  in  the  fracture  due  to  eversion 
the  upper  end  of  the  lower  fragment  is  displaced 
towards  the  tibia,  while  in  the  lesion  due  to  in- 
version it  is  displaced  from  that  bone.  From  a 
careful  examination  of  all  the  cases  of  fracture  of 
the  lower  end  of  the  fibula  admitted  into  the 
London  Hospital  during  the  time  I  held  the  post 
of  surgical  registrar  there,  I  convinced  myself  that 
the  lesion  is  much  more  frequently  due  to  eversion 
than  to  inversion  of  the  foot.  I  think  it  may  be 
said  that  a  fracture  of  the  lower  end  of  the  fibula 
due  to  simple  inversion  of  the  foot  is  not  pos- 
sible unless  the  external  lateral  ligament  remains 
entire. 


002  THE    LOWER    EXTREMITY  [Chap. 

In  the  outward  luxation,  better  known  as 
Pott's  fracture,  the  condition  is  such  as  has  just 
been  described  in  connexion  with  the  effects  of 
eversion  of  the  foot  upon  the  fibula.  That  bone  is 
always  broken  some  2  or  3  inches  above  the  malle- 
olus, the  deltoid  ligament  is  torn,  or  the  tip  of 
the  inner  malleolus  wrenched  off.  The  astragalus 
is  so  rotated  laterally  that  the  foot  is  much 
everted,  its  outer  edge  raised,  while  its  inner 
edge  rests  upon  the  ground.  The  inferior  tibio- 
fibular ligaments  remain  intact.  If  they  yield,  an 
unusual  form  of  fracture  or  dislocation  is  pro- 
duced, as  already  stated.  Boyer  relates  a  case, 
considered  to  be  unique,  where  the  foot  was  lux- 
ated outwards,  but  without  any  fracture  of  the 
fibula.  That  bone,  however,  had  been  forced  up- 
wards entire,  and  its  head  dislocated  from  the 
articular  facet  of  the  tibia.  A  horizontal  disloca- 
tion outwards,  without  rotation  of  the  foot  and 
without  fracture  of  the  fibula,  is  possible  if  the 
inferior  tibio-fibular  ligaments  are  entirely  torn. 

In  Dupuytren's  fracture  (a  rare  injury)  the 
fibula  is  fractured  from  1  to  3  inches  above  the 
malleolus,  the  inferior  tibio-fibular  ligaments  are 
entirely  lacerated,  or  the  portion  of  the  tibia  to 
which  they  are  attached  is  torn  away,  and  remains 
connected  with  the  lower  fragments  of  the  fibula. 
The  foot  is  dislocated  horizontally  outwards,  and 
is  drawn  upwards,  the  extent  of  the  upward  dis- 
placement depending  upon  the  height  at  which  the 
fibula  breaks. 

In  the  inward  luxation  the  external  lateral 
ligament  is  torn  or  the  tip  of  the  outer  malleolus 
dragged  away,  the  deltoid  ligament  is  intact,  but 
the  internal  malleolus  is  commonly^  broken  by^  the 
violence  with  which  the  astragalus  is  brought  into 
contact  with  it.  That  bone  itself  may  be  broken, 
and  is  in  any  case  rotated  laterally,  so  that  the 
foot  is  inverted  and  its  inner  border  much  raised. 
In  all  forms  of  this  dislocation,  whether  simple 
or  complicated,  the  inferior  tibio -fibular  ligament 
remains  intact. 


XX Vj  ANKLE    AND    FOOT  ($03 

2.  The  antero-posterior  dislocations :  Back- 
wards; forwards.  These  injuries  are  brought 
about  by  great  force  applied  to  the  foot  while  the 
leg  is  fixed,  or  more  commonly  by  sudden  arrest 
of  the  foot  during  some  violent  impulse  given  to 
the  body,  as  on  jumping  from  a  carriage  when 
in  motion.  In  the  luxation  backwards  the  astra- 
galus is  displaced  behind  the  tibia,  while  the 
articular  surface  of  the  latter  bone  rests  upon 
the  scaphoid  and  cuneiform  bones.  The  anterior 
and  posterior  ligaments  are  entirely  torn,  and  a 
great  part  also  of  the  two  lateral  bands.  The 
fibula  is  broken  some  2  or  3  inches  above  the  mal- 
leolus, and  there  is  usually  a  fracture  also  of  the 
inner  malleolus. 

The  luxation  forwards  is  of  extreme  rarity. 
In  the  few  reported  cases  one  or  both  malleoli 
were  broken.  R.  W.  Smith  believes  that  the  dis- 
location is  never  complete. 

3.  The  dislocation  upwards.  In  this  rare  acci- 
dent the  inferior  tibio-fibular  ligaments  are  rup- 
tured, the  two  bones  are  widely  separated  at  their 
lower  ends,  and  the  astragalus  is  driven  up  be- 
tween them.  The  anterior  and  posterior  ligaments 
are  entirely  ruptured,  but  the  lateral  ligaments 
usually  escape  with  but  some  slight  laceration. 
The  accident  appears  to  be  generally  caused  by 
a  fall,  the  patient  alighting  flat  upon  the  soles  of 
the  feet.  Mr.  Bryant  records  a  case  in  which 
both  feet  were  similarly  dislocated  upwards. 

The  foot. — There  are  two  arches  in  the  foot, 
an  antero-posterior  and  a  transverse. 

1.  The  antero= posterior  arch  has  its  summit  at 
the  astragalus.  It  may  be  considered  as  composed 
of  two  piers.  The  hinder  pier  consists  of  the  os 
calcis,  the  anterior  pier  of  the  scaphoid,  cunei- 
form and  metatarsal  bones.  The  astragalus  forms 
the  keystone  of  the  arch,  the  head  of  the  bone 
especially  performing  that  function  (Fig.   124). 

The  foot  rests  upon  the  heel,  the  heads  of  the 
metatarsal  bones,  and  the  outer  margin  of  the  foot 
(Fig.   126).     The  hinder  pier  is  solid,  is  made  up 


G04 


THE    LOWER    EXTREMITY 


[Chap. 


of  a  strong  bono,  and  contains  only  one  joint.  It 
serves  to  support  the  main  part  of  the  weight  of 
the  body,  and  gives  a  firm  basis  of  attachment 
to  the  muscles  of  the  calf.  The  anterior  part  of 
the  arch,  on  the  other  hand,  contains  many  small 
bones  and  a  number  of  complicated  joints.  It 
serves  to  give  elasticity  to  the  foot,  and  to 
diminish  the  effect  of  shocks  received  upon  the 
sole  of  the   foot.     The  comparative  value  of  the 


Fig.  124. 


-Antero-posterior  section  of  the  foot, 

(Rildinger.) 


1,  Tibia  ;  2,  astragalus  ;  3,  os  calcis ;  4,  scaphoid  ;  5,  int.  cuneiform  ; 
6,  first  metatarsal  bone  ;  7  and  8,  phalanges  of  great  toe. 


two  piers  of  the  arch  in  this  latter  respect  can  be 
estimated  by  jumping  from  a  height  and  alight- 
ing first  upon  the  heels  and  then  upon  the 
balls  of  the  toes.  The  inner  part  of  the  arch 
is  much  more  curved  than  the  outer,  and  forms 
the  instep. 

2.  The  transverse  arch  is  most  marked  across 
the  cuneiform  bones.  It  gives  much  elasticity  to 
the  foot  and  affords  protection  to  the  vessels  of  the 
sole. 


XXV]    INVERSION    AND    EYERSION    OF    FOOT   605 

These  two  arches  result  from  the  shape  of  the 
component  bones,  and  are  maintained  by  the  vari- 
ous ligaments  and  muscles  of  the  sole.  The  pero- 
neus  longus  tendon,  and  nearly  all  the  ligaments 
which  connect  the  first  and  second  rows  of  tarsal 
bones  on  both  the  plantar  and  dorsal  aspects, 
are  inclined  forwards  and  inwards,  and  by  this 
arrangement  are  well  adapted  to  maintain  the 
integrity  of  the  transverse  as  well  as  of  the 
antero-posterior  arch. 

The  movements  of  inversion  and  eversion, 
whereby  the  foot  is  adapted  to  the  ground  on 
which  it  treads,  occur  at  the  subastragaloid 
joints.  These  are  two  in  number — (l)  the  anterior 
subastragaloid  joint  between  the  head  of  the  astra- 
galus and  three  other  parts  :  (a)  sustentaculum 
tali;  (b)  inferior  calcaneo-scaphoid  ligament; 
(c)  scaphoid  (Fig.  124) ;  (2)  posterior  subastra- 
galoid between  the  body  of  the  astragalus  and  os 
calcis.  The  posterior  is  separated  from  the  an- 
terior joint  by  the  interosseous  ligament.  A  third 
joint  is  also  concerned  in  these  important  move- 
ments, viz.  that  between  the  os  calcis  and  cuboid. 
The  muscles  which  produce  inversion  are  (1)  tibi- 
alis posticus,  (2)  tibialis  anticus.  The  first  pro- 
duces eversion  with  plantar  flexion,  the  others 
with  dorsal  flexion.  The  flexor  muscles  of  the 
toes  assist  the  first,  the  extensor  of  the  great  toe 
the  second.  Eversion  is  produced  by  (1)  peroneus 
longus,  (2)  peroneus  brevis,  (3)  peroneus  tertius, 
(4)  the  extensor  longus  digitorum.  The  first  pro- 
duces eversion  with  plantar  flexion,  the  others 
with  dorsal  flexion.  Thus  there  are  four  groups 
of  muscles  acting  on  the  subastragaloid  articula- 
tions which  balance  and  determine  the  movements 
of  the  foot,  and  four  positions  in  which  they  may 
fix  the  foot :  (1)  inversion  with  plantar  flexion 
(talipes  equino-varus) ;  (2)  eversion  with  plantar 
flexion  (talipes  equino-valgus)  ;  (3)  inversion  with 
dorsi-flexion  (talipes  calcaneo-varus) ;  (4)  eversion 
with  dorsi-flexion  (talipes  calcaneo-valgus).  The 
position   assumed   will   depend  on   the  group   or 


606  THE    LOWER    EXTREMITY  [Chap. 

groups  of  muscles  which  are  paralysed  or  weak- 
ened. Eversion  is  limited  by  the  inferior  calcaneo- 
scaphoid  ligament  and  the  structures  along  the 
inner  side  of  the  sole  of  the  foot — the  abductor 
hallucis,  plantar  fascia,  and  the  tibial  muscles. 
Inversion  is  limited  by  the  tuberosity  of  the 
scaphoid  coming  in  contact  with  the  sustenta- 
culum tali,  the  peroneal  muscles,  and  ligaments 
along  the  outer  border  of  the  foot.  The  move- 
ments of  inversion  and  eversion  correspond  to 
supination  and  pronation,  but  in  the  upper  ex- 
tremity these  are  produced  between  radius  and 
ulna,  whereas  in  the  lower  extremity  they  occur 
almost  entirely  between  the  astragalus  and  the 
rest  of  the  foot. 

Dislocation  of  the  astragalus. — This  bone  is 
sometimes  luxated  alone,  being  separated  from 
its  connexions  with  the  os  calcis,  the  tibia,  the 
fibula,  and  the  scaphoid  bone.  The  displacement 
may  be  either  forwards,  backwards,  or  laterally. 
The  luxation  forwards  is  by  far  the  most  common 
lesion,  the  next  in  frequency  being  a  luxation 
outwards  and  forwards.  In  these  injuries  the 
interosseous  ligament  between  the  os  calcis  and 
astragalus  is  entirely  torn,  as  are  also  the  greater 
part  of  the  lateral  ligaments  of  the  ankle,  and 
the  various  bands  that  connect  the  astragalus  with 
the  os  calcis  and  scaphoid.  In  all  instances  the 
malleoli  are  brought  nearer  to  the  sole.  Radio- 
graphy has  shown  that  fracture  not  infrequently 
accompanies  dislocation  of  the  astragalus.  When 
it  is  remembered  that  the  astragalus  is  the  key- 
stone of  the  plantar  arch,  and  must  receive  the 
chief  impact  in  all  accidents  which  force  the 
weight  on  the  feet,  the  fracture  of  its  neck  or 
of  its  body  becomes  intelligible. 

Dislocation  of  the  os  calcis. — This  bone,  al- 
though often  fractured,  is  very  rarely  luxated. 
When  displaced,  however,  it  is  usually  displaced 
outwards,  and  is  torn  away  from  its  attachments 
to  the  astragalus  and  cuboid,  or  from  the  former 
bone  alone. 


XXV]  DISLOCATIONS    OF    FOOT  007 

Subastragaloid    dislocations    of   the    foot. —  In 

these  lesions,  which  are  not  very  uncommon,  the 
astragalus  remains  in  position  between  the  tibia 
and  fibula,  while  the  rest  of  the  foot  is  dislo- 
cated below  that  bone.  The  luxation,  therefore, 
concerns  the  anterior  and  posterior  subastraga- 
loid joints.  The  foot  may  be  displaced  either 
forwards,  backwards,  or  laterally.  The  forward 
dislocation  is  extremely  rare,  and  the  lateral  luxa- 
tions are  nearly  always  oblique.  In  the  most  usual 
displacements  the  loot  is  dislocated  outwards 
or  inwards,  and  is  at  the  same  time  carried  back- 
wards. These  luxations  are  frequently  compound, 
especially  when  lateral.  They  are,  as  a  rule, 
incomplete  as  regards  the  anterior  subastragaloid 
joint,  while,  on  the  other  hand,  the  displacement 
of  the  astragalus  from  the  scaphoid  is  in  nearly 
every  instance  complete.  In  all  cases  the  inter- 
osseous ligament  between  the  os  calcis  and  astraga- 
lus must  be  torn,  and  there  will  also  be  more 
or  less  laceration  of  the  ligaments  joining  the 
astragalus  to  the  scaphoid  and  to  the  malleoli. 
The  malleoli  are  very  often  fractured. 

It  is  only  necessary  to  notice  in  any  detail  the 
two  lateral  luxations,  as  being  the  only  common 
forms.  In  the  inward  dislocation  the  foot  is  in- 
verted, its  inner  border  is  raised,  is  shortened, 
and  rendered  concave,  while  its  outer  border  is 
lengthened  and  made  convex.  The  deformity 
much  resembles  that  of  talipes  varus.  The  head 
of  the  astragalus  with  the  outer  malleolus  forms 
a  projection  at  the  outer  aspect  of  the  foot,  while 
below  them  a  deep  hollow  exists.  The  inner 
border  of  the  os  calcis  is  very  prominent  at  the 
internal  side  of  the  limb,  while  the  inner  malleolus 
is  buried  in  the  hollow  left  by  the  displacement  of 
that  bone.  The  calcaneum  and  scaphoid  are  ap- 
proximated. In  the  outward  luxation  the  foot 
is  abducted,  its  outer  border  is  raised,  and  the 
deformity  produced  is  not  unlike  that  of  talipes 
valgus.  The  outer  malleolus  is  lost  in  the  hollow 
caused  by  the  eversion  of  the  foot,  while  the  tibial 


608  THE    LOWER    EXTREMITY  [Chap. 

malleolus  and  head  of  the  astragalus  form  a  pro- 
jection on  the  inner  aspect  of  the  limb. 

The  mediotarsal  joint  is  situated  between  the 
head  of  the  astragalus  and  scaphoid  on  the  inner 
side  of  the  foot,  and  os  calcis  and  cuboid  on 
the  outer.  The  inner  is  part  of  the  anterior  sub- 
astragaloid joint  (see  p.  605),  while  the  outer  has 
a  separate  synovial  cavity.  It  should  be  noted 
that  the  movements  of  turning  the  toes  either 
in  or  out  take  place  mainly  at  the  hip-joint; 
while  the  turning  of  one  edge  of  the  foot  either 
up  or  down  is  a  movement  that  mostly  concerns 
the  subastragaloid  joints. 

Club-foot.— It  is  usual  to  divide  the  various 
forms  of  talipes,  or  club-foot,  into  four  main 
divisions,  viz.  :  (l)  T.  equinus;  (2)  T.  calcaneus; 
(3)  T.  varus;  and  (4)  T.  valgus.  Four  secondary 
forms  result  from  combinations  of  these  prin- 
cipal varieties,  viz.  :  T.  equino-varus,  T.  equino- 
valgus,  T.  calcaneo-varus,  and  T.  calcaneo-valgus, 
corresponding  to  the  four  positions  assumed  by 
the  foot  at  the  subastragaloid  articulation  (see 
p.   605). 

1.  Talipes  equinus.  In  this  deformity  the  heel 
is  drawn  up,  and  the  patient  walks  upon  the  balls 
of  the  toes.  The  contracting  muscles  are  those  of 
the  calf,  attached  to  the  tendo  Achillis.  The 
paralysed  muscles  are  the  extensors  of  the  foot. 
There  is  plantar  flexion  and  marked  inversion  of 
the  foot.  In  a  well-marked  case  the  os  calcis  is 
much  raised,  and  may  even  be  brought  in  contact 
with  the  tibia.  The  astragalus  is  displaced  down- 
wards and  projects  upon  the  dorsum.  The  foot 
tends  to  become  more  and  more  inverted,  until 
at  last  the  scaphoid  may  even  touch  the  sustenta- 
culum. The  ligaments  of  the  sole  are  usually 
much  contracted. 

2.  Talipes  calcaneus.  In  this  form  of  club-foot 
the  toes  are  drawn  up  and  the  patient  walks  upon 
the  heel.  The  contracting  muscles  are  the  ex- 
tensors on  the  anterior  aspect  of  the  limb.  The 
os    calcis    is    rendered    more    vertical,    and    the 


XXV]  CLUB-FOOT  609 

astragalus  becomes  so  obliquely  placed  that  part 
of  its  upper  articular  surface  may  project  beyond 
the  tibia  in  a  backward  direction. 

3.  Talipes  varus.  This  is  the  commonest  form. 
Certain  features  of  the  fcetal  foot  are  retained 
in  an  exaggerated  degree.  In  a  well-marked  con- 
genital case  there  is  a  threefold  deformity  :  (1) 
The  heel  is  drawn  up  by  the  muscles  attached  to 
the  tendo  Achillis;  (2)  the  foot  is  inverted  by  the 
contraction  of  the  tibialis  anticus  and  posticus; 
(3)  the  sole  is  contracted  by  the  flexor  longus 
digitorum  muscle  and  the  shrinking  of  the  plantar 
fascia  and  ligaments.  The  neck  of  the  astragalus 
is  elongated  and  deflected  downwards  and  inwards 
to  a  greater  extent  than  in  the  normal  foot.  In 
the  adult  the  neck  of  the  astragalus  is  deflected 
inwards  to  the  axis  of  its  body  at  an  angle  of  10° ; 
in  the  newly  born  at  an  angle  of  25° ;  and  in 
talipes  varus  at  an  angle  of  50°.  The  scaphoid 
is  displaced  upwards  and  inwards,  until  its 
inner  border  often  touches  the  internal  malleolus. 
The  three  cuneiform  bones  follow  the  scaphoid, 
and  the  cuboid  becomes  the  lowest  bone  in  the 
tarsus.  The  outer  border  of  the  cuboid  forms  an 
angle  with  the  os  calcis,  and  the  tendons  of  the 
peroneus  longus  slip  backwards  from  the  groove 
in  the  cuboid  to  lie  on  the  os  calcis.  The  anterior 
border  of  the  internal  lateral  ligament  is  con- 
tracted and  unduly  prominent.  There  is  thus  a 
marked  degree  of  inversion. 

4.  In  talipes  <  valgus  the  foot  assumes  perma- 
nently the  position  of  eversion.  The  contracting 
muscles  are  the  two  peronei.  In  a  well-markeu 
congenital  case  the  os  calcis  is  found  a  little 
raised  and  the  astragalus  is  displaced  forwards 
and  downwards.  The  scaphoid  is  so  rotated  that 
its  inner  part  is  depressed  and  its  outer  raised. 
The  internal  portion  of  the  bone  forms  one  of 
the  two  projections  obvious  on  the  inner  side  of 
the  foot,  the  other  prominence  being  formed  by 
the  head  of  the  astragalus.  The  cuboid  is  found 
to  be  a  little  rotated  outwards.     The  arch  of  the 


610  THE    LOWEIl    EXTREMITY  [Chap. 

foot  is  lost,  and  all  those  ligaments  are  stretched 
that  serve  to  support  and  maintain  that  arch. 

Of  the  mixed,  or  secondary,  forms  of  talipes 
nothing  need  be  said.  They  are  the  results  merely 
of  a  combination  of  the  primary  varieties. 

As  trouble  is  often  caused  in  talipes  by  pres- 
sure being  brought  to  bear  upon  an  unusual  part 
of  the  foot,  it  is  well  to  note  upon  what  portion 
of  the  member  the  patient  treads  in  the  different 
varieties  of  the  deformity.  In  varus  the  "  tread  " 
is  mainly  upon  the  outer  side  of  the  5th  meta- 
tarsal bone ;  in  valgus  upon  the  internal  malle- 
olus and  scaphoid;  in  equinus  upon  the  bases  of 
all  the  toes;  in  equino-varus  upon  the  base 
of  the  little  toe ;  in  equino-valgus  upon  the  base  of 
the  great  toe;  in  all  forms  of  calcaneus  upon  the 
heel.  In  cases  of  extreme  and  obstinate  club-foot 
wedges  of  bone  are  sometimes  removed  by  the 
operation  known  as  tarsectomy.  Thus  in  talipes 
equino-varus  the  base  of  the  wedge  will  be  on  the 
outer  side  of  the  foot,  and  will  be  mainly  repre- 
sented by  the  cuboid;  the  apex  will  be  at  the 
scaphoid. 

Flat-foot  and  splay-foot  are  the  names  given 
to  a  deformity  due  probably  to  the  yielding 
of  certain  ligaments,  whereby  the  arch  of  the 
foot  is  lost  and  the  sole  becomes  more  or  less 
perfectly  flat.  The  foot,  at  the  same  time,  is 
abducted,  and  the  outer  border  is  often  a  little 
raised,  so  that  the  patient  walks  mainly  upon 
the  inner  side  of  the  foot.  This  deformity  is  met 
with  in  those  who  stand  a  great  deal,  and  is  the 
direct  result  of  yielding  of  the  muscles  which 
maintain  the  foot  in  a  position  of  inversion — 
especially  the  tibialis  anticus  and  posticus.  It 
is  only  when  these  muscles  become  exhausted  and 
yield  that  the  ligaments  are  strained  and  elon- 
gated, for  it  may  be  accepted  as  a  law  that  the 
normal  strain  at  a  joint  falls  on  the  muscles,  the 
ligaments  only  coming  into  action  in  limiting  the 
extent  of  ^  movements.  The  inferior  calcaneo- 
scaphoid  ligament  is  lax  in  the  standing  posture; 


XXV] 


FLAT-FOOT 


CdII 


the  weight  of  the  head  of  the  astragalus  is  then 
supported  by  the  tibialis  posticus  (Fig.   125). 

As  is  well  known,  the  muscles  of  the  leg  and 
foot  become  more  quickly  exhausted  when  stand- 
ing than  when  walking,  for  in  the  standing 
posture  the  muscles  which  invert  the  foot  are 
maintained  in  a  condition  of  tonus,  whereas  in 
walking  they  have  alternate  periods  of  action  and 
rest.  Hence  in  those  whose  occupations  entail 
prolonged  periods  of  standing,  the  muscles  which 
maintain  the  inversion  of  the  foot  become  ex- 
hausted— especially    the    tibialis    posticus;    they 


Am  5up.  An.  LiQAME/NTy 
Tibialis  Anticusv 
Mid. Cuneiform 
Int.  Cuneiform 


Jem  do  AcniLLi  s 
Fl.l.Dicitorum 

l/IT.  AlALLEOLUS 

Tibialis  Post.  , 

SuSTErtT.TALI 


/lEAD  OFASTRACALUS 

Mr.  Calcaaieo  Scap*  Liq. 
Tuberosity  op5cap/ioid 


Fig.   125. — Dissection   of  a  flat-foot  from  the  inner  side. 


gradually  yield,  and  the  superincumbent  weight 
of  the  body  then  falls  on  the  structures  which 
limit  eversion  of  the  foot,  especially  the  inferior 
calcaneo-scaphoid  ligament,  on  which  the  head  of 
the  astragalus  then  comes  torest  (Fig.  125).  When 
the  weight  falls  on  this  ligament  it  begins  to 
yield;  the  head  of  the  astragalus  is  pressed  for- 
wards, downwards,  and  inwards  by  the  superin- 
cumbent weight,  and  the  foot  beyond  becomes,  as 
a  consequence,  over-extended  and  turned  out  (Fig. 
125).  The  os  calcis  slants  inwards,  and  its  anterior 
end  is  depressed.  The  sustentaculum  tali,  the 
head  of  the  astragalus,  and  the  scaphoid  tubercle 


612 


THE    LOWER    EXTREMITY 


[Chap. 


form  prominences  on  the  inner  side  of  the  foot, 
and  may  rest  on  the  ground  (Fig.  125).  The  long 
and  short  plantar  ligaments  also,  which  contribute 
so  much  to  the  maintenance  of  the  arch  of  the 
foot,  in  time  yield,  and  allow  of  a  still  greater 
degree  of  deformity.  There  is  a  stretching  also 
of  the  deltoid  ligament.  In  neglected  cases  the 
distortion  is  rendered  more  or  less  permanent  by 


BCD 

Fig.   126. — Various  forms  of  foot-prints. 

A,  Of  normal  foot  with  high  arch. 

B,  „         „         „     also  with  high  arch. 

C,  „         „         „     with  low  arch . 

D,  „  fiat  foot. 


alterations  in  the  shape  of  the  tarsal  bones,  and 
by  a  contraction  of  such  ligaments  as  have  been 
relaxed  by  the  deformity.  The  scaphoid  and  in- 
ternal cuneiform  become  markedly  wedge-shaped, 
with  the  apices  directed  to  the  dorsum  of  the  foot 
(Fig.  125).  The  foot  being  abducted,  and  its  outer 
border  a  little  raised,  the  peronei  muscles  become 
relaxed,  shortened,  and  contribute  to  the  perma- 
nency of  the  disorder.     It  will  be  understood  that 


XXV]         FRACTURES    OF    TARSAL   BONES  613 

the  abnormal  pressure  brought  to  bear  upon  the 
various  tarsal  bones  and  articulations  will  cause 
severe  pain  to  be  often  associated  with  this  affec- 
tion. The  calf  muscles  waste,  owing  to  the  arch 
of  the  foot  having  lost  its  rigidity  and  being  no 
longer  able  to  support  the  weight  of  the  body. 

Imprints  of  normal  feet  vary  much  in  form 
{see  Fig.  126).  Dr.  Lovett,  of  Boston,  is  of  opinion 
that  the  feet  which  come  in  contact  with  the 
ground  at  only  two  parts — at  the  heel  behind, 
and  along  the  pad  of  the  foot  in  front— are  those 
which  are  most  prone  to  break  down  (Fig.  126,  a). 
In  flat  foot  the  inner  border  of  the  foot  also  comes 
in  contact  with  the  ground,  so  that  the  area  be- 
tween the  heel,  the  plantar  pad,  and  the  outer 
margin  of  the  foot,  left  blank  in  the  normal  im- 
print, become  partially  or  completely  filled  up 
(Fig.   126). 

It  may  be  noted  that  the  medio-tarsal  joint, 
which  is  so  conspicuously  involved  in  the  distor- 
tion, is  supplied  by  the  anterior  tibial,  musculo- 
cutaneous, and  external  plantar  nerves. 

The  tarsal  bones,  owing  to  their  spongy  char- 
acter, are  readily  broken  by  direct  violence, 
as  in  severe  crushes.  The  soft  parts  that  cover 
these  bones  being  scanty  upon  the  dorsal  aspect 
of  the  foot,  it  follows  that  these  accidents  are 
often  compound  and  associated  with  much  lacera- 
tion of  the  integuments. 

The  tarsal  bone  the  most  frequently  fractured 
is  the  os  calcis.  This  bone  may  be  broken  by  a 
fall  upon  the  heel,  and  in  many  instances  has 
been  the  only  one  fractured  by  such  an  accident. 
A  few  cases  have  been  recorded  of  fracture  of 
the  calcaneum  by  muscular  violence,  the  muscles 
producing  the  lesion  being  those  attached  to  the 
tendo  Achillis.  Thus,  Sir  A.  Cooper  reports  the 
case  of  a  woman,  aged  42,  in  whom  a  large 
fragment  of  the  posterior  part  of  the  os  calcis 
was  torn  away  by  the  muscles  and  drawn  some 
2j  inches  away  from  the  heel.  The  accident  was 
caused    by    her    taking    a    false    step.      Abel    has 


614  THE    LOWER    EXTREMITY  [Chap. 

collected  three  cases  of  fracture  of  the  susten- 
taculum tali.  He  believes  that  this  injury  may 
be  produced  by  falls  upon  the  sole  or  by  extreme 
inversion  of  the  foot,  whereby  the  astragalus  is 
forced  violently  against  the  process. 

The  astragalus  alone  may  be  broken  by  a  fall 
upon  the  feet,  and  such  accidents  are  often  associ- 
ated with  fractures  of  both  that  bone  and  the  os 
calcis.  It  must  be  noted,  however,  that  in  a  fall, 
when  the  patient  alights  upon  the  feet,  the  tibia 
and  fibula  are  much  more  likely  to  be  broken  than 
are  the  tarsal  bones,  since  the  bones  of  the  leg 
transmit  the  weight  of  the  body  directly,  whereas 
that  weight  is  much  diffused  and  broken  up  when 
passing  through  the  foot  with  its  many  bones  and 
joints. 

The  metatarsal  bones  and  phalanges  are  nearly 
always  broken  by  direct  violence.  I  had,  how- 
ever, under  my  care  at  the  London  Hospital  a 
man  who  had  broken  the  shafts  of  the  three  outer 
metatarsal  bones  by  simply  slipping  off  the  edge 
of  the  curb.  Since  the  introduction  of  X-rays  as 
a  means  of  diagnosis,  fractures  of  the  metatarsal 
bones,  especially  of  the  fifth,  and  of  the  phalanges, 
are  found  to  occur  not  infrequently,  and  often  as 
the  result  of  a  movement  or  accident  which  seems 
totally  insufficient  to  produce  such  lesions. 

With  regard  to  the  luxations  of  the  foot  not 
yet  considered,  it  may  be  said  that  the  cuboid 
is  never  dislocated  alone.  Walker  reports  a  case 
of  dislocation  of  the  scaphoid  alone,  that  structure 
being  quite  separated  from  the  astragalus  and 
cuneiform  bones.  The  accident  was  brought  about 
by  alighting  upon  the  ball  of  the  foot  when  jump- 
ing, and  the  little  bone  was  found  projecting  on 
the  dorsum.  Mr.  Bryant  has  mentioned  an  in- 
stance of  dislocation  of  the  scaphoid  inwards. 
As  a  rule,  however,  this  bone  when  displaced  is 
dislocated  along  with  the  astragalus. 

Of  the  cuneiform  bones  the  one  most  often 
luxated  alone  is  the  internal.  The  attachments 
of  the  tendons  of  the  tibialis  anticus  and  peroneus 


XXV]  OSSIFICATION    OF    TARSUS  615 

longus  about  the  internal  cuneiform  and  first 
metatarsal  bones  render  it  common  for  the  latter 
to  follow  its  tarsal  colleague  when  dislocated. 
Mr.  Luke  has  recorded  a  case  of  incomplete  luxa- 
tion of  all  three  cuneiform  bones  upwards,  and 
at  least  three  cases  have  been  described  of  disloca- 
tion of  the  internal  bone  upwards  and  backwards, 
together  with  a  like  displacement  of  all  the  meta- 
tarsals. 

One  or  more  of  the  metatarsal  bones  may  be 
luxated,  or  the  entire  series  may  be  displaced 
upwards,  downwards,  inwards,  or  outwards,  the 
first-named  lesion  being  the  most  common.  In 
rarer  instances,  one  bone  has  been  thrown  in  one 
direction  and  its  fellow  or  fellows  in  another. 

Ossification  of  the  tarsus. — At  birth  the  tar- 
sus is  mainly  cartilaginous.  Ossification  begins 
in  the  os  calcis  in  the  sixth  month  and  in  the 
astragalus  in  the  seventh  month  of  foetal  life. 
The  centre  for  the  cuboid  appears  at  birth,  and 
in  the  scaphoid,  the  last  to  ossify,  in  the  third 
year.  It  is  not  until  puberty  that  the  cartilage 
of  the  tarsal  bones  is  completely  ossified.  Like  the 
epiphyses  of  long  bones  the  tarsal  bones  are  en- 
tirely formed  in  cartilage,  there  being  no  peri- 
osteal formation.  Hence  it  is  possible,  as  Ogston 
has  shown,  to  enucleate  the  ossific  centres  from  the 
tarsal  bones  of  children  who  are  the  subjects  of 
club-foot  and  by  remodelling  the  cartilaginous 
capsules  left  behind,  obtain  new  ossifications  of 
a  more  normal  form. 

Dislocation  of  the  proximal  phalanx  of  the 
great  toe  is  often  very  difficult  to  reduce,  as  is 
also  the  case  in  the  corresponding  luxation  of 
the  thumb.  When  the  displacement  is  dorsal,  the 
difficulty  is  probably  due  to  the  sesamoid  bones, 
which  are  embedded  in  the  glenoid  ligament  or 
fibrocartilaginous^  plate.  "  Like  the  glenoid  liga- 
ments, the  sesamoid  bones  are  much  more  firmly 
connected  with  the  phalanx  than  with  the  meta- 
tarsal bone,  and  thus  get  torn  away  and  shut 
back  behind  the  head  of  the  metatarsal  bone;  or 


616 


THE    LOWEE    EXTREMITY 


TChap. 


Fig,  127,  — iOblique  antero- 
posterior section  of  foot,  to 

I  show  the  synovial  cavities 
of  the  tarsus.     (Rudinger.) 

1,  Tibia  ;  2,  fibula  ;  3,  astragalus  ;  4, 
os  calcis ;  5,  external  lateral 
ligament ;  6,  internal  lateral 
ligament ;  7,  interosseous  liga- 
ment between  astragalus  and 
os  caleis  :  8,  head  of  astragalus  ; 
9,  scaphoid  ;  10,  11.  and  12,  the 
thi-ee  cuneiform  bones ;  13, 
cuboid. 


it    may    be    that   the 
sesamoid     bones,    re- 
taining    their     con- 
nexions   with    the 
lateral    ligaments   of 
the     joint     as     well 
as     with     the     short 
flexor     tendons,     are 
separated    from    one 
another,  and  so  allow 
the  head  of  the  meta- 
tarsal   bone    to    pass 
forwards,    and     thus 
become  nipped,  as  it 
were,  in  a  button-hole 
between    them "    (Sir 
Henry    Morris).      A 
partial  dislocation  of 
the  proximal  phalanx 
outwards  on  the  head 
of      the      metatarsal 
bone  of  the  great  toe 
constitutes    the    con- 
dition       known       as 
hallux    valgus.      The 
inner     lateral     liga- 
ment of  the  joint  is 
elongated,    while   the 
outer    is   contracted. 
In      hallux      rigidus 
this  joint  is  slightly 
flexed  and  rigid,  due 
probably  to  a  reflex 
contraction     of     the 
flexor  brevis  hallucis. 
The  second  toe  is  com- 
monly    longer     than 
the     others,     and     is 
more  liable  to  assume 
the    form    known    as 
"  hammer  toe.' '     The 
proximal  phalanx  in 


XXV]        SYME'S    AMPUTATION    AT    ANKLE  617 

such  a  form  is  extended,  while  the  middle  is 
strongly  flexed.  The  condition  is  commonly  in- 
herited, and  is  due  to  a  contraction  of  the  glenoid 
and  lateral  ligaments  of  the  proximal  phalangeal 
joint.     The  extensor  tendon  is  also  contracted. 

There  are  six  synovial  cavities  in  the  foot, 
excluding  that  of  the  ankle-joint,  viz.  one  for 
the  posterior  subastragaloid  joint,  a  second 
for  the  anterior  subastragaloid,  a  third  between 
the  os  calcis  and  cuboid,  a  fourth  between  the 
latter  bone  and  the  two  outer  metatarsals,  a  fifth 
for  the  joint  between  the  inner  cuneiform  and 
first  metatarsal  bones,  and  a  sixth  for  the  remain- 
ing articulations  (Fig.  127).  These  synovial  cavities 
tend  greatly  to  diffuse  disease  among  the  various 
bones  of  the  foot  when  once  one  bone  has  become 
inflamed.  The  best  position,  therefore,  for  bone 
disease,  with  reference  to  the  question  of  exten- 
sion, w°uld  be  in  the  hinder  parts  of  either  the 
os  calcis  or  astragalus,  and  one  of  the  worst  posi- 
tions would  be  assumed  by  disease  involving  the 
scaphoid  bone. 

Syme's  amputation  at  the  ankle  (Fig.  128). — In 
the  heel-flap  are  cut  the  integuments,  the  external 
saphenous  nerve  and  vein,  the  peroneus  longus, 
peroneus  brevis,  tibialis  posticus,  flexor  longus 
digitorum,  flexor  longus  hallucis,  tendo  Achillis, 
points  of  origin  of  the  flexor  brevis  digitorum 
and  of  the  two  abductor  muscles,  and  the  internal 
and  external  plantar  arteries  and  nerves. 

In  the  dorsal  flap  are  cut  the  integuments, 
tibialis  anticus,  extensor  communis  digitorum,  ex- 
tensor proprius  hallucis,  peroneus  tertius,  anterior 
tibial  vessels  and  nerve,  musculo-cutaneous  nerve, 
and  internal  saphenous  nerve  and  vein.  The  posi- 
tion of  the  principal  structures  divided  is  shown 
in  Fig.  128.  It  is  not  usual  to  dissect  up  any  of 
the  muscular  tissue  of  the  sole,  as  shown  in  Agatz's 
plate.  It  should  be  noted  that  the  integuments 
of  the  heel  derive  their  blood  supply,  which  is 
very  free,  mainly  from  the  external  calcaneal 
branch  of  the  posterior  peroneal  artery  on  the 
u* 


618 


THE    LOWER    EXTREMITY 


[Chap. 


-Syme's    amputation. 

{Agatz.) 

Tibia  ;  b,  fibula  ;  e,  tibialis  anticus  ; 
d,  extensor  proprius  hallucis  ;  e, 
extensor  communis  digitorum  ; 
/,  peroneus  tertius  ;  g,  flexor  lon- 
gus  hallucis  ;  7),  tibialis  posticus  ; 
f,  flexor  longus  digitorum  ;  j,  pe- 
roneus brevis;  k,  peroneus  lon- 
gus ;  I,  tendo  Achillis ;  m,  some 
muscles  of  the  sole  that  are  not 
usually  left  in  this  operation  ;  n, 
anterior  tibial  vessels  ;  o,  poste- 
rior tibial  vessels ;  p,  posterior 
tibial  nerve. 


outer  side,  and  the 
internal  calcaneal 
from  the  external 
plantar  on  the 
inner. 

If  the  heel  in- 
cision is  carried 
sufficiently  far  back 
to  divide  the  trunk 
of  the  posterior  tibial 
artery,  the  heel  flap 
is  deprived  of  the 
last-named  source  of 
blood  supply.  The 
posterior  tibial  ar- 
tery bifurcates  upon 
a  line  drawn  from 
the  tip  of  the  inner 
malleolus  to  the  cen- 
tre of  the  convexity 
of  the  heel. 

The  nerves  supply- 
ing the  integuments 
of  the  heel  are  the 
calcaneal  branch  of 
the  external  saphe- 
nous and  the  cal- 
caneal and  plantar 
cutaneous  twigs  from 
the  posterior  tibial. 

In  Pirogoff's  am- 
putation the  parts 
divided  in  the  an- 
terior flap  are  the 
same  as  in  Syme's 
operation.  In  the  heel 
or  sole  flap  the  same 
structures  also  are 
cut  as   in  the  corre- 


sponding flap  in  a 
Syme,  with  the  exception  that  the  tendo  Achillis 
is     not     divided,    the    flexor     brevis     digitorum, 


XXV] 


CHOPART'S    AMPUTATION 


619 


abductor  hallucis,  abductor  minimi  digiti,  and 
flexor  accessorius  are  divided  more  extensively, 
and  the  plantar  vessels  are  cut  farther  from  the 
bifurcation. 

Chopart's  operation  is  an  amputation  at  the 
mediotarsal  joint  (Fig.  129).  In  the  dorsal  flap 
are  cut  the  integuments,  the  extensor  communis 
and  brevis 
digitorum,  ex- 
tensor proprius 
hallucis,  tibialis 
anticus,  pero- 
neus  tertius  and 
brevis,  the  mus- 
culo -  cutaneous, 
anterior  tibial, 
and  two  saphen- 
ous nerves,  the 
dorsal  artery, 
and  the  dorsal 
plexus  of  veins. 
In  the  plantar 
flap  are  found 
divided  the  in- 
teguments, plan- 
tar fascia,  flexor 
brevis  digit- 
orum, abductors 
of  the  great  and 
little  toes,  flexor 
accessorius,  and 
tibialis  posticus 
tendon.  If  the 
flap  be  well  dis- 
sected up,  parts 
of  the  short 
flexors  of  the 
great  and  little  toes,  the  abductor  hallucis,  and 
transversiis  pedis  will  be  found  cut  in  the  flap. 
The  tendons  of  the  long  flexors  of  the  digits  and 
great  toes,  the  peroneus  longus,  and  the  plantar 
vessels  and  nerves  are  also  divided  (Fig.  129). 


-Chopart's  operation. 

(Agatz.) 

a,  Astragalus  ;  b,  os  calcis ;  c,  extensor  pro- 
prius hallucis  ;  d,  tibialis  anticus  ;  c,  ex- 
tensor communis  digitorum;  /, peroneus 
longus  ;  g,  adductor  minimi  digiti  ;  //, 
flexor  brevis  digitorum  ;  i,  flexor  longus 
digitorum  ;  j,  abductor  hallucis  ;  k,  flexor 
longus  hallucis  ;  /,  dorsalis  pedis  artery  ; 
m,  internal  plantar  artery  ;  ft,  external 
plantar  artery. 


620 


THE    LOWER    EXTREMITY 


[Chap. 


Lisfranc's    operation,     or    amputation   through 
the  tarso-metatarsal  line  of  joints  (Fig.  130). — In 

the  dorsal  flap  the 
same  structures  are 
divided  as  are  cut  in 
the  corresponding 
flap  in  Chopart's 
amputation.  In  the 
plantar  flap  also  the 
parts  divided  are 
the  same  as  in  that 
procedure,  with  the 
exception  that  the 
flexor  accessor  ius 
and  the  tendon  of 
the  tibialis  posticus 
escape  section.  The 
articulations  be- 
tween the  three  outer 
metatarsals  and  the 
corresponding  tarsal 
bones  form  a  line 
sufficiently  straight 
to  be  traversed  by 
the  knife  in  one  cut 
when  once  the  blade 
has  been  introduced. 
The  joint  also  be- 
tween the  first  meta- 
tarsal and  internal 
cuneiform  bones  is  in 
a  straight  line  and 
readily  opened.  The 
most  difficult  part  of 
the  disarticulation 
concerns  the  separa- 
tion of  the  second  metatarsal  bone,  which  is  deeply 
lodged  between  the  tarsal  segments.  The  chief 
bond  of  union  between  this  bone  and  the  tarsus 
is  effected  by  a  strong  interosseous  ligament  that 
passes  between  it  and  the  internal  cuneiform.  In 
Fig.   130  the  knife  is  placed  in  the  position  re- 


Fig,  130. — Lisfranc's  operation. 

{Agatz.) 

a,  &,  c,  Inner,  middle,  and  outer  cunei- 
form bones  ;  d,  cuboid  ;  e,  f,  the 
metatarsal  bones  ;  g,  tibialis  an- 
ticus ;  h,  extensor  proprius  hal- 
lucis ;  i,  extensor  communis 
digitorum ;  j,  extensor  brevis 
digitorum  ;  k,  extensor  tendons  ; 
I,  dorsalis  pedis  artery. 


XXV]       NERVE    SUPPLY    OF    LOWER    LIMB 


621 


quired  to  divide  that  ligament,   and  in  Fig.   131 
the  ligament  is  shown. 

In  the  subastragaloid  amputations  a  disarticu- 
lation is  effected  at  the  subastragaloid  articula- 
tions. The  astragalus  is  the  only  bone  of  the 
foot  left  behind,  and  forms  the  summit  of  the 
stump. 

JVerve    supply    of     the     lower    limb.  —  In 

Fig.   132  is  shown  the  cutaneous  nerve  supply  of 
the  inferior  extremities  on  both  the  anterior  and 


Mid.  Cuneiform 


Int.   Cuneiform 


2nd  Metatar. 


Fig.  131.— The  ligament  of  Lisfranc.      (After  Poirier. 


the  posterior  aspect,  and  in  Fig.  133  are  seen  the 
cord  segments  from  which  they  are  derived. 
Paralyses  of  the  lower  limbs  are  common,  but  are 
more  often  due  to  some  lesion  in  the  inferior 
segment  of  the  cord  than  to  damage  received  by 
any  one  individual  nerve.  Cases,  however,  are 
recorded  where  a  single  trunk  has  been  injured 
and  a  limited  form  of  paralysis  has  followed  in 
consequence. 

Paralysis    of    the    anterior    crural    nerve    has 
been  caused  by  injuries  to  the  lower  part  of  the 


V  9  I 


Fig,  132,— Cutane- 
ous nerve  supply 
of  lower  limb. 


10 


Anterior  aspect.— 1,  Ilioinguinal ;  2,  genito-crural ;  8,  external  cuta- 
neous ;  4.  middle  cutaneous  ;  5,  internal  cutaneous  ;  6,  patellar 
plexus  ;  7  branches  of  external  popliteal ;  8,  internal  saphenous  ; 
9,  musculocutaneous  ;  10,  external  saphenous ;  11,  anterior 
tibial. 

Posterior  aspect— I,  2,  and  3,  Small  sciatic;  4,  external  cutaneous  ; 
5,  internal  cutaneous  ;  6,  internal  saphenous  ;  7,  branches  of  ex- 
ternal popliteal  ;  8,  short  saphenous  :i  9,  posterior  tibial;  10,  in- 
ternal saphenous  ;  11,  internal  plantar  ;'12;  external  plantar. 

622 


Fig.  133. — Showing  the  skin  areas  in  the  lower  extremity 
supplied  by  the  lumbar  and  sacral  segments  of  the 
spinal  cord.     (After  Head.) 

On  each  area  is  indicated  the  segment  of  the  cord  by  which  it  is 
supplied.    For  the  nerves  supplying  each  area  see  Fig.  132. 

623 


624  THE    LOWER    EXTREMITY  IChap. 

vertebral  column  implicating  the  cauda  equina, 
by  fractures  of  the  pelvis,  by  tumours  of  the 
pelvis,  by  psoas  abscess,  by  fractures  and  dis- 
locations of  the  femur,  and  by  stabs  in  the  region 
of  the  groin.  In  this  nerve  lesion  the  patient  is 
unable  to  flex  the  hip  or  to  raise  the  body  from 
the  recumbent  position  (ilio-psoas).  The  adductor 
muscles :  may  simulate  the  action  of  the  flexors 
of  the  hip,  but  it  will  be  observed  that  they  rotate 
and  adduct  the  thigh  as  well  as  flex  it.  The  power 
of  extending  the  leg  at  the  knee  is  lost  (quadri- 
ceps extensor  cruris) ;  the  function  of  the  sar- 
torius  is  destroyed  and  that  of  the  pectineus  im- 
paired. Sensation  is  impaired  in  parts  supplied 
by  the  internal  and  middle  cutaneous  nerves  and 
the  long  saphenous  nerve. 

Paralysis  of  the  obturator  nerve  alone  is  a 
rare  condition,  although  it  may  be  found  associ- 
ated with  a  like  lesion  of  the  preceding  trunk. 
It  may  be  brought  about  by  the  pressure  exer- 
cised upon  the  nerve  in  cases  of  obturator  hernia 
and  by  the  foetal  head  during  delivery.  The 
muscles  implicated  are  the  adductors,  gracilis, 
and  external  obturator.  The  patient  is  unable  to 
press  the  knees  together,  or  to  cross  the#  legs. 
Rotation  outwards  is  difficult,  but  sensation  is 
scarcely  affected  in  the  skin  supplied. 

Paralysis  of  the  internal  popliteal  nerve. — 
There  is  inability  to  flex^  the  ankle  and  to  flex 
the  toes  (flexor  longus  digitorum,  flexor  proprius 
hallucis,  tibialis  posticus,  gastrocnemius,  and 
soleus).  The  patient  is  unable  to  stand  upon  the 
toes,  owing  to  loss  of  function  in  the  two  last- 
named  muscles.  t  The  power  of  inverting  the  foot 
is  impaired  (tibialis  posticus),  and  lateral  move- 
ment in  the  toes  is  lost  owing  to  paralysis  of  all 
the  small  muscles  of  the  sole.  Sensation  is  im- 
paired over  the  plantar  aspect  of  the  toes,  the 
sole,  and  in  part  of  the  lower  half  of  the  back 
of  the  leg. 

In  paralysis  of  the  external  popliteal  nerve 
the  action  of  the  muscles  on  the  front  of  the  leg  is 


XXV]      NERVE    SUPPLY    OF   LOWER    LIMB         G25 

lost.  The  foot  hangs  down  and  the  toes  catch  the 
ground  in  walking.  The  foot  can  be  neither  dorsi- 
flexed  nor  everted  (extensor  communis  digitorum, 
extensor  proprius  hallucis,  peroneal  muscles). 
Adduction  is  imperfect,  owing  to  paralysis  of 
the  tibialis  anticus.  Extension  of  the  toes  is 
only  possible  to  the  slight  extent  effected  by  the 
interossei.  The  arch  of  the  foot  becomes  flattened 
owing  to  loss  of  the  support  furnished  by  the 
peroneus  longus.  Sensation  is  impaired  over  the 
front  and  outer  side  of  the  leg  and  on  the  dorsum 
of  the  foot,  and  also  over  some  part  of  the  back  of 
the  leg,  owing  to  paralysis  of  the  communicans 
peronei. 

The  fibres  destined  for  any  particular  muscle 
are  not  assorted  in  one  fasciculus  until  near  their 
point  of  exit  from  the  nerve  trunk ;  hence  a  nerve 
trunk  such  as  the  internal  popliteal  may  be  partly 
divided  without  any  apparent  effect.  This  cir- 
cumstance is  taken  advantage  of  in  cases  of  in- 
fantile paralysis.  In  a  case  where  the  external 
popliteal  is  affected,  action  of  the  extensor  mus- 
cles may  be  restored  by  suturing  that  nerve  to 
a  slip  partially  separated  from  the  internal 
popliteal. 

When  the  great  sciatic  nerve  is  paralysed, 
there  will  be,  in  addition  to  the  loss  or  function 
in  the  two  preceding  nerves,  an  inability  to  flex 
the  knee  owing  to  paralysis  of  the  hamstrings, 
while  rotation  of  the  limb  may  be  impaired  by 
loss  of  power  in  the  quadratus  femoris  and  ob- 
turator internus.  Mr.  Sherren  found  that  the 
knee  may  still  be  flexed  in  such  cases  through 
the  action  of  the  gracilis,  and  that  sensation 
was  completely  lost  in  only  part  of  the  sole  of 
the  foot. 

A  knowledge  of  the  segments  of  the  cord 
from  which  the  nerves  of  the  lower  limb  arise 
often  assists  g  the  surgeon  in  localizing  certain 
lesions.  Section  of  a  nerve  root,  as  may  happen 
in  fracture  of  the  spine,  or  destruction  of  its 
centre  in  the  spinal  cord,  gives  rise  to  paralysis 


(520  THE    LOWER    EXTREMITY    l[Chap.  XXV 

in  a  definite  group  of  muscles  and  anaesthesia 
of  a  certain  area  of  skin.  The  skin  areas 
supplied  by  the  lumbar  and  sacral  segments  are 
shown  in  Fig.  133,  and  these  segments,  accord- 
ing to  Kocher,  innervate  the  following  groups  of 
muscles  :  Third  lumbar,  the  psoas,  iliacus,  pec- 
tineuSj  sartorius  and  adductors;  fourth  lumbar, 
quadriceps  extensor  cruris;  fifth  lumbar,  gluteus 
medius  and  minimus,  tensor  vaginae  femoris  and 
hamstrings;  first  sacral,  gluteus  maximus,  short 
external  rotators  of  the  hip-joint,  peronei,  exten- 
sors of  the  toes  and  flexors  of  the  ankle;  second 
sacral,  gastrocnemius,  soleus,  long  flexors  of  the 
toes  and  extensors  of  the  ankle-joint  and  muscles 
of  the  sole. 


PART   VI 
THE  SPINE  AND  SPINAL  CORD 

CHAPTER  XXVI 

THE  SPINE 

The  vertebral  column  combines  in  a  remarkable 
way  many  very  different  and  complicated  func- 
tions. It  acts  as  the  central  pillar  of  the  body, 
and  as  the  column  that  supports  the  weight  of 
the  head.  It  connects  the  upper  and  lower  seg- 
ments of  the  trunk.  It  gives  attachments  to  the 
ribs.  It  has  the  property  of  mitigating  the  effects 
of  shocks  that' are  transmitted  from  various  parts 
of  the  body.  It  permits,  to  a  wonderful  degree,  of 
a  number  of  most  complicated  movements;  and, 
lastly,  forms  a  solid  tube  for  the  reception  of 
the  spinal  cord. 

It  owes  much  of  its  elasticity,  and  of  its  power 
of  breaking  up  divers  forces  communicated  to  it, 
to  its  curves.  Of  the  four  curves,  two,  the  dorsal 
and  sacral,  are  primary  and  are  due  to  the  forma- 
tion of  the  thoracic  and  pelvic  cavities,  depending 
mainly  upon  the  shape  of  the  bones.  The  other 
two,  the  cervical  and  lumbar,  are  compensatory 
curves,  and  depend  #  mainly  upon  the  shape  of 
the  intervertebral  discs.  The  dorsal  and  sacral 
curves  appear  in  fcetal  life ;  the  lumbar  and 
cervical  curves  appear  after  birth,  following  the 
f>27 


628  THE    SPINE    AND    SPINAL    CORD        [Chap. 

assumption  of  the  erect  position.  The  infant's 
spine  appears  straight.  The  only  marked  curve 
seen  in  the  back  of  the  young  child  is  a  general 
curving  of  the  column  backwards,  a  kyphosis. 
When  the  infant  is  first  encouraged  to  sit  erect, 
this  is  the  outline  assumed  by  the  spine,  and  in 
some  weakly  children,  and  especially  in  those 
afflicted  with  rickets,  this  curvature  is  often  very 
pronounced.  The  intervertebral  discs,  twenty- 
three  in  number,  make  up  nearly  one-fourth  of  the 
entire  length  of  the  spine.  If  the  discs  be  removed, 
and  the  vertebrae  be  articulated  in  the  dry  state, 
the  cervical  and  lumbar  convexities  almost  dis- 
appear, and  the  column  tends  to  present  one  great 
curvature,  the  concavity  of  which  is  forwards,  and 
the  most  marked  part  of  which  corresponds  to 
a  point  just  below  the  middle  of  the  dorsal  region. 
This  somewhat  resembles  the  curve  seen  in  the 
spines  of  the  aged,  and  in  such  individuals  it  may 
be  to  no  small  extent  due  to  the  shrinking  of  the 
intervertebral  discs. 

It  is  by  means  of  the  discs  that  the  move- 
ments of  the  spine  are  in  the  main  permitted, 
and  it  will  be  found  that  they  are  most  developed 
in  regions  where  most  movement  is  allowed.  They 
act  also  as  springs  in  giving  elasticity  to  the 
column,  and  in  economizing  muscular  action, 
while  at  the  same  time  they  play  the  part  of 
buffers  in  modifying  the  effect  of  shocks  trans- 
mitted along  the  spine. 

Although  the  motion  permitted  between  any 
two  individual  vertebrae  is  not  extensive,  yet  the 
degree  of  movement  capable  of  being  exercised 
in  the  column  as  a  whole  is  considerable.  While 
lateral  movements  and  those  of  flexion  and  ex- 
tension are  restricted  in  the  dorsal  region,  those 
of  rotation  are  free ;  hence  scoliosis  of  the  spine 
is  most  marked  in  this  region.  Movements  from 
back  to  front  (flexion  and  extension)  and  from 
side  to  side  (lateral  flexion)  are  freest  in  the 
cervical,  dorso-lumbar,  and  lumbar  regions.  From 
a    surgical    point   of    view    the    weakest    part    of 


XXVI]  THE    ERECT    POSTURE  629 

the  spinal  column  is  between  the  9th  dorsal  and 
3rd  lumbar  vertebrae.  Here  side-to-side  and  back- 
to-front  movements  occur  most  freely ;  above 
this  region  the  spine  is  supported  by  the  thorax ; 
below  the  intervertebral  discs  are  larger  and 
stronger,  and  the  supporting  ligaments  and 
muscles  better  developed. 

It  is  impossible  to  insist  too  strongly  on  the 
fact  that  the  muscles  of  the  back  and  trunk 
are  the  sole  agents  in  maintaining-  the  spine 
erect.  The  moment  they  are  thrown  out  of  action 
the  spinal  column  loses  its  rigidity  and  collapses. 
All  four  groups  of  muscles  which  act  on  the  spine 
are  concerned  :  the  extensors  (erector  spinas) ; 
the  flexors  (rectus  abdominis,  longus  colli,  psoas) ; 
the  lateral  flexors  (erector  spinas,  quadratus  lum- 
borum,  internal  and  external  oblique,  intercos- 
tals,  and  levatores  costarum);  rotators  (external 
and  internal  oblique,  multifidus  spinas,  semi- 
spinalis,  intercostals,  and  levatores  costarum). 
By  these  muscles  the  vertebras  are  maintained 
balanced  on  their  intervertebral  discs,  one  above 
the  other.  The  ligaments  are  slack,  and  the  sur- 
faces of  the  articular  processes  are  in  only  light 
contact.  When  the  muscles  approach  exhaustion, 
owing  to  prolonged  maintenance  of  the  erect  pos- 
ture, partial  relief  may  be  obtained  by  allowing 
a  certain  degree  of  rotation  and  lateral  flexion 
to  take  place.  Thereby  the  articular  processes  are 
brought  into  firm  contact,  the  ligaments  become 
somewhat  tightened,  and  a  certain  degree  of  pas- 
sive support  is  obtained.  School  children,  for 
instance,  after  sitting  some  time  with  their  bodies 
erect,  place  an  arm  on  the  desk  and  rotate  the 
body  until  the  vertebras  are  partly  locked.  In 
this  posture  the  muscles  are  rested,  but  if  the 
position  be  much  indulged  in,  the  muscles  become 
weakened  in  their  action,  and  the  spine  may 
assume  permanently  a  partial  scoliosis. 

Scoliosis.  —  In  very  few  people  do  the  spines 
of  the  vertebras  lie  in  a  perfectly  straight  line 
down  the  back.     There  is  commonly  a  slight  de- 


630  THE    SPINE    AND    SPINAL    COED       [Chap. 

gree  of  lateral  curvature.  If  the  pelvis  be  tilted 
laterally,  as  when  the  limbs  are  unequal  in  length, 
a  compensatory  lateral  curve  is  produced.  In 
scoliosis,  lateral  curvature  is  combined  with  a 
rotation  of  the  vertebrae,  the  spinous  processes 
turning  to  one  side  of  the  median  line  and  the 
bodies  to  the  opposite.  It  is  a  disease  of  ado- 
lescents, due  to  a  weakness  of  the  spinal  muscles, 
which  are  unable  to  maintain  the  vertebrae 
in  the  position  necessary  for  the  erect  posture. 
Kach  vertebra  is  provided  with  three  levers,  a 
posterior  (the  spinous  process)  and  two  lateral 
(the  transverse  processes  and  attached  ribs).  The 
erector  spinae  acts  on  the  lateral  levers;  the 
multifidus  spinae  and  muscles  for  the  upper  ex- 
tremity on  the  posterior.  It  is  through  train- 
ing these  muscles  by  suitable  exercises  that  the 
vertebrae  can  be  restored  to,  and  maintained  in, 
their  normal  positions.  The  ribs  form  the  most 
powerful  spinal  levers ;  in  exercises  to  restore 
deformities  of  the  spine  this  should  be  kept  in 
mind.  All  the  respiratory  muscles  act  indirectly 
through  the  costal  levers  on  the  spine;  hence 
respiratory  exercises  are  suitable  for  the  treat- 
ment of  postural  defects.  Dr.  Halls  Dally  has 
shown  that  in  all  forms  of  breathing,  and  es- 
pecially in  forced  respiration,  spinal  movements 
are  always  present. 

Sprains  of  the  vertebral  column. — The 
many  joints  and  ligaments  of  the  Dart,  and  the 
varied  and  violent  movements  to  which  it  may  be 
exposed,  render  it  very  liable  to  be  the  seat  of 
sprains.  These  injuries,  however,  cannot  reach 
any;  great  magnitude,  for  so  closely  are  the  in- 
dividual vertebrae  articulated,  that  any  force 
severe  enough  to  produce  other  than  slight  tearing 
of  the  ligaments  will  tend  to  cause  a  fracture  or 
dislocation  of  the  bones. 

Sprains  are  most  commonly  met  with  in  the 
cervical  and  lumbar  segments  of  the  spine.  This 
localization  is  due  to  the  mobility  of  these^  parts, 
and    to    their    tendency    to    diffuse    any    violence 


XXVI]      SPRAINS    OF    VERTEBRAL    COLUMN        631 

transmitted  to  them,  and  so  to  render  it  more 
general.  For  it  is  to  be  noted  that  the  more 
localised  an  injury,  the  more  likely  it  is  to  pro- 
duce a  fracture  or  dislocation  rather  than  a 
sprain. 

In  the  cervical  region,  also,  the  tendency  to 
sprain  is  increased  by  the  near  articulation  of  the 
column  with  the  head,  and  the  possibility  of  any 
violence  applied  to  the  skull  being  transmitted 
to  the  spine.  Since  the  introduction  of  Rontgen 
rays  in  the  diagnosis  of  such  injuries  it  has 
become  apparent  that  many  lesions  formerly 
regarded  as  sprains  are  really  fractures  of  the 
body  of  the  vertebra  or  of  the  neural  arch 
(Sherren). 

Sprains  of  the  spine  are  not  apt  to  be  asso- 
ciated with  the  external  evidences  of  ecchymosis, 
since  between  the  skin  and  the  column  there  inter- 
vene not  only  many  layers  of  muscles,  but  also 
dense  expansions  of  fascia. 

It  has  already  been  pointed  out  that  sprains  in 
the  loin,  produced  by  severe  bending  forwards 
of  the  column,  may  be  associated  with  some 
damage  to  the  kidney  and  consequent  hematuria 
(p.  430). 

A  sprained  back  is  often  the  seat  of  a  con- 
siderable degree  of  pain  and  stiffness,  that  per- 
sists long  after  the  immediate  effects  of  the  lesion 
must  have  passed  away.  Such  a  condition  may  be 
understood  by  noticing  that  the  column  presents 
a  vast  number  of  separate  articulations,  each 
provided  with  cartilage,  synovial  membrane,  and 
capsular  ligaments.  These  joints  have  no  quali- 
ties that  exempt  them  from  the  common  evils 
incident  to  sprains  of  more  superficial  articula- 
tions; and  there  is  little  doubt  that  the  long-felt 
pain  and  inconvenience  often  depend  upon  some 
synovitis  of  the  vertebral  joints.  In  a  few  cases 
this  synovitis  has  gone  on  to  suppuration,  and  in 
one  instance  at  least  the  pus  so  formed  found  its 
way  into  the  spinal  canal  and  induced  some  mis- 
chief in  the  cord. 


G32  THE    SPINE    AND    SPINAL    COED       [Chap  . 

Fractures  and  dislocations  of  the  spine.— 

The  effects  of  violence  applied  to  the  column  are 
much  diminished  by  the  general  elasticity  of  the 
spine,  by  its  curves,  and  by  the  circumstance  that 
it  is  composed  of  a  number  of  separate  segments. 
Each  vertebra  meets  the  one  immediately  above  or 
below  it  at  three  points  of  contact,  the  body  and 
the  two  articulating  processes.  The  bodies  are 
separated  by  the  intervertebral  disc,  which  acts 
as  an  excellent  spring  or  buffer  in  modifying  the 
effects  of  violence.  The  articulating  processes  are 
more  or  less  wedge-shaped,  the  thin  edge  of  one 
being  applied  to  the  base  of  the  other.  When  a 
force  that  tends  to  compress  the  vertebrae  together 
is  applied  to  the  column,  the  bases  of  the  two 
wedges  are  brought  into  more  and  more  close  rela- 
tion, and  thus  an  increasing  resistance  is  offered 
to  the  compressing  power. 

The  parts  of  the  spine  most  liable  to  injury  are 
(1)  the  atlan to-axial,  (2)  the  cervico-dorsal,  and 
(3)  the  dorso-lumbar.  In  the  atlanto-axial  region 
the  parts  not  only  enjoy  a  very  considerable  degree 
of  movement  but  are  very  directly  influenced  by 
many  forms  of  violence  applied  to  the  head.  In 
the  two  other  regions  it  will  be  noted  that  a 
flexible  part  of  the  spine  joins  a  comparatively 
rigid  segment  of  it,  and  thus  violence  applied  to 
the  column  in  either  of  these  districts  is  apt  to  be 
concentrated  rather  than  diffused.  The  sternum 
and  ribs  act  as  a  splint  to  the  dorsal  part  of  the 
column.  The  mechanism  is  in  a  way  illustrated 
by  the  circumstance  that  a  fishing-rod  when  it 
snaps  commonlv  breaks  near  a  joint,  that  is  to 
say,  at  a  spot  where  a  flexible  segment  of  the  rod 
meets  a  less  elastic  portion.  In  the  dorso-lumbar 
region,  moreover,  the  vertebrae,  although  they 
have  to  support  almost  as  much  weight  as  have 
those  of  the  lumbar  region  proper,  are  yet  dispro- 
portionately small  in  size.  Being  placed,  also, 
near  the  middle  of  the  column,  they  can  be  in- 
fluenced on  all  sides  by  a  powerful  amount  of 
leverage.     The  gravity  of  all  injuries  to  the  spine 


XXVI]  INJURIES    TO    THE    SPINE  633 

depends  upon  the  risk  of  damage  to  the  cord  en- 
closed in  the  column.  Apart  from  this  complica- 
tion, fractures  and  dislocations  in  this  region  are 
apt  to  do  well,  and,  if  the  patient  survive,  the 
former  lesions  nearly  always  heal  readily. 

The  position  of  the  cord  within  the  vertebral 
canal  and  the  arrangement  of  its  membranes  are 
such  that  it  presents  many  facilities  for  escaping 
injury  from  violence.  These  will  be  dealt  with 
subsequently  in  speaking  of  the  cord  itself.  It 
may,  however,  be  noted  here  that  the  construction 
of  the  vertebrae,  and  their  relation  to  one  another, 
are  of  a  character  to  afford  much  protection  to  the 
cord,  even  in  cases  where  they  themselves  are  ex- 
tensively damaged.  "  Being  lodged  in  the  centre 
of  the  column,  it  (the  cord)  occupies  neutral 
ground  to  forces  which  might  cause  fracture.  For 
it  is  a  law  in  mechanics  that  when  a  beam,  as  of 
timber,  is  exposed  to  breakage,  and  the  force 
does  not  exceed  the  limits  of  the  strength  of 
the  material,  one  division  resists  compression, 
another  laceration  of  the  particles,  while  the 
third,  between  the  two,  is  in  a  negative  condi- 
tion" (Jacobson,  Holmes's  "System").  Now,  it 
happens  that  fractures  of  the  spine  are  most  often 
due  to  violence  that  bends  the  column  forwards. 
The  anterior  segment,  in  such  a  case,  will  be  sub- 
ject to  compression,  the  posterior  to  laceration, 
and  the  intermediate  portion  will  be  in  a  neutral 
condition.  When  the  spine  is  examined,  it  will 
be  found  that  its  anterior  part,  composed  of  the 
large  cancellous  bodies,  is  excellently  adapted  to 
resist  the  effects  of  compression,  while  its  pos- 
terior parts,  composed  of  slighter  and  more  com- 
pact bones  and  surrounded  by  many  strong  liga- 
ments, are  well  arranged  to  resist  the  effects  of  a 
tearing  force.  The  spinal  cord,  situated  between 
these  two  divisions,  occupies  the  position  of  least 
danger. 

The  vertebrae  may  be  fractured  without  being 
dislocated,  but  a  dislocation  without  a  fracture  is 
rarely  possible. 


634  THE    SPINE    AND    SPINAL    CORD       [Chap. 

It  would  appear,  indeed,  that  a  luxation  of  the 
spine,  with  no  fracture  of  the  bone,  cannot  occur 
in  either  the  dorsal  or  lumbar  regions.  Mr. 
Jacobson,  in  the  essay  above  referred  to,  writes  : 
"  I  believe  I  am  correct  in  stating  that  there  is  no 
case  recorded,  and  thoroughly  verified,  in  recent 
years,  of  dislocation  of  the  lumbar  or  dorsal  ver- 
tebrae unaccompanied  with  any  fracture  of  the  body, 
transverse  or  articular  processes."  Dislocation 
without  fracture  is  met  with  in  the  cervical  spine. 
When  it  occurs  it  most  often  involves  the  fifth 
vertebra,  which,  with  the  rest  of  the  column  above 
it,  is  displaced  forwards  and  downwards.  Luxa- 
tions in  other  directions  have  been  noted,  but 
they  are  extremely  uncommon.  The  possibility  of 
luxation  in  the  cervical  region  without  fracture 
is  explained  by  the  small  size  of  the  vertebral 
bodies,  the  obliquity  of  their  articular  processes, 
and  the  relatively  slight  opposition  they  offer  to 
displacement  when  compared  with  like  processes 
in  the  other  parts  of  the  column.  The  luxation  is 
usually  bilateral  and  incomplete,  and  the  result  of 
a  forcible  bending  of  the  head  and  upper  part 
of  the  spine  forwards  and  downwards.  When 
situated  high  up  the  displacement  may  be  appre- 
ciated by  an  examination  of  the  part  through  the 
pharynx.  The  degree  of  deformity  may  be  slight, 
and  the  spinal  injury  overlooked.  The  paralysis 
below  the  level  of  the  dislocation  may  be  in- 
complete; so  that  a  diagnosis  of  injury  to  the 
brachial  plexus  may  be  made  when  it  is  really 
one  of  the  spine  and  cord  (Sherren).  In  the 
complete  bilateral  dislocation  the  cord  is  usually 
hopelessly  crushed.  These^  luxations  have  been 
reduced  by  forcible  extension,  although  the  cir- 
cumstances under  which  such  a  procedure  is 
advisable  are  neither  frequent  nor  very  distinctly 
marked. 

Since,  in  severe  injuries,  dislocation  and  frac- 
ture are  so  usually  associated,  it  is  common  to 
deal  with  these  lesions  under  the  title  of  fracture- 
dislocation.      These    may    be    due    to    (l)    in- 


XXVI]     FRACTURE-DISLOCATIONS    OF    SPINE     G35 

direct,  or  (2)  direct  violence.  (1)  The  injuries 
from  indirect  violence  are  by  far  the  more  com- 
mon. They  are  due  to  a  violent  bending  of  the 
head,  or  of  the  spine  above  the  seat  of  lesion,  for- 
wards and  downwards.  Thus,  the  cervical  spine 
has  been  more  than  once  broken  by  a  "  header  " 
into  shallow  water;  while  the  dorsal  vertebrae 
have  been  fractured  and  displaced  by  the  acute 
bending  of  the  column  produced  by  a  heavy  sack 
falling  upon  the  back  of  the  neck. 

This  form  of  injury  is  most  commonly  met  with 
in  the  cervical  and  upper  dorsal  regions.  These 
parts  of  the  column  possess  great  mobility,  the 
bodies  that  compose  them  are  not  large,  and  are 
influenced  by  violence  applied  to  the  head.  In  a 
well-marked  case  there  is  some  crushing  of  the 
vertebrae  involved,  and  the  usual  deformity  de- 
pends upon  the  sliding  of  the  centrum  above 
downwards  and  forwards  upon  the  centrum  below. 
Complete  displacement  of  any  two  vertebrae  from 
one  another  is  prevented  by  a  locking  of  the  pos- 
terior processes.  ^  In  some  cases  the  luxation  is 
complete,  a  condition  that  is  least  frequently  met 
with  in  the  lumbar  spine. 

In  the  cervical  and  dorsal  regions,  the  parts, 
after  the  dislocation,  may  often  be  returned  to 
their  normal  position ;  but  in  the  loins  this  re- 
placement is  usually  impossible,  owing  to  the  lock- 
ing of  the  large  and  powerful  articular  processes. 
In  the  neck  the  laminae  and  spines  may  be  frac- 
tured, while  the  articulating  processes,  being 
broad  and  nearly  horizontal,  usually  escape,  even 
when  there  is  much  displacement  of  the  parts.  In 
the  dorsal  spine  the  laminae  and  articular  pro- 
cesses are  always  torn  when  displacement  occurs. 
In  the  lumbar  region  the  articular  processes 
usually  escape  fracture,  although  they  are  vio- 
lently torn  asunder.  In  all  cases  there  is  more  or 
less  laceration  of  the  intervertebral  discs,  and  the 
supraspinous,  interspinous,  and  capsular  liga- 
ments are  torn,  as  are  also  the  ligamenta  subflava. 
When  the  bodies  are  much  crushed  and  displaced 


636  THE    SPINE    AND    SPINAL    CORD       [Chap. 

the  anterior  and  posterior  common  ligaments  are 
commonly  ruptured. 

(2)  In  the  fracture-dislocations  due  to  direct 
violence  the  lesion  may  be  at  any  part  of  the 
spine.  Some  form  of  direct  violence  is  applied 
to  the  back,  and  the  column  tends  to  become  bent 
backwards  at  the  spot  struck.  In  the  previous 
class  of  injuries  it  will  be  noted  that  the  anterior 
segments  of  the  vertebrae  suffer  compression,  while 
the  posterior  suffer  from  the  effects  of  laceration 
and  a  tearing  asunder  of  their  parts.  In  lesions 
due  to  direct  violence  the  circumstances  of  the  in- 
jury are  reversed;  the  posterior  segments  tend  to 
be  crushed  together,  while  the  bodies  on  the  front 
of  the  spine  are  separated. 

Much  displacement  is  very  rarely  met  with  in 
this  form  of  accident.  To  produce  separation 
of  the  vertebrae  the  violence  must  be  extreme, 
and  as  a  rule  the  force  expends  itself  upon  a 
crushing  of  the  hinder  portions  of  the  spinal 
segments.  It  follows  from  this  that  injury  to 
the  cord  is  less  common  and  less  severe  in  lesions 
due  to  direct  violence  than  in  those  due  to  indirect 
violence.  In  the  atlanto-axial  region  the  atlas 
and  occipital  bone  have  been  dislocated  from  one 
another  by  direct  violence,  although  the  most  fre- 
quent lesion  is  a  dislocation  of  the  former  for- 
wards upon  the  axis,  a  lesion  usually,  if  not 
always,  associated  with  fracture  of  the  odontoid 
process.  The  transverse  process  of  the  atlas  can 
be  felt  between  the  mastoid  process  and  the  jaw 
when  it  is  in  normal  position  (E.   Corner). 

The  spinous  processes  may  be  broken  off  as  a 
result  of  well-localized  blows.  The  prominent 
spines  in  the  lower  cervical  region  and  the  long 
processes  of  the  dorsal  tract  of  the  column  are 
those  that  usually  suffer.  The  lumbar  spines  are 
less  freauently  broken,  being  comparatively  small 
and  well  protected  by  the  great  muscles  of  the 
back. 

The  transverse  processes  and  laminae  can 
scarcely  be  fractured  alone.     In  great  exertions, 


XXVI]  LAMINECTOMY  637 

as  in  lifting  or  carrying  heavy  weights  on  the 
back,  the  psoas  and  quadratus  lumborum  may 
actually  fracture  the  transverse  processes  of  the 
lumbar  vertebrae  to  which  they  are  attached. 

In  several  instances  of  fracture-dislocation  and 
of  fracture  alone  the  spine  has  been  trephined,  or 
rather  portions  of  the  laminae  and  spinous  pro- 
cesses have  been  resected  (laminectomy).  By  this 
means  the  spinal  canal  has  been  freely  opened  up, 
effused  blood  has  been  allowed  to  escape,  and  the 
cord  has  been  freed  from  pressure.  The  laminae 
are  divided  as  near  the  transverse  process  as  pos- 
sible, and  the  tough  ligamenta  subflava  require 
careful  division. 

The  column  is  reached  through  a  median  in- 
cision, and  the  great  muscular  masses  are  cleared 
from  the  spinous  processes  and  laminae  on  either 
side.  The  wound  being  nearly  median,  the  bleed- 
ing is  not  excessive.  The  dorsal  spinal  plexus  of 
veins  lies  along  the  spines  and  over  the  laminae. 
On  the  deep  surface  of  the  laminae  lie  the  pos- 
terior longitudinal  spinal  veins 

This  operation  has  also  been  carried  out  with 
success  in  cases  of  paralysis  due  to  the  pressure 
upon  the  cord  by  displaced  bone  or  inflammatory 
exudations  in  caries  of  the  spine  (Pott's  disease). 
It  has  to  be  noted,  however,  in  the  last-named 
class  of  case,  that  the  condition  exhibits  a  ten- 
dency to  spontaneous  cure. 


CHAPTE11   XXVII 

THE   SPINAL   CORD 

The  spinal  cord  is,  in  the  adult,  about  18  inches 
in  length,  and  extends  from  the  lower  margin 
of  the  foramen  magnum  to  the  lower  edge  of 
the  body  of  the  first  lumbar  vertebra.  In  some 
cases  it  ends  at  the  second  lumbar,  and  in  other 
instances  at  the  last  dorsal  vertebra.  It  is  to  be 
noted  also  that  in  flexion  of  the  spine  the  cord  is  a 
little  raised.  When  the  body  is  bent  and  the  arms 
are  stretched  out  the  lumbar  part  is  raised  10  mm. 
In  the  earlier  months  of  total  life  the  medulla 
spinalis  occupies  the  whole  length  of  the  verte- 
bral canal,  but  after  the  third  month  the  canal 
and  lumbar  and  sacral  nerves  grow  so  much 
faster  than  the  cord,  that  by  the  time  of  birth 
it  reaches  no  farther  than  the  third  lumbar  ver- 
tebra. It  is  obviously  a  great  advantage,  in  cases 
of  injury,  that  the  spinal  cord  does  not  occupy 
that  part  of  the  vertebral  pillar  which  joins  the 
base  of  the  column,  and  which  permits  not  only 
of  considerable  movement,  but  is  liable  also  to 
frequent  wrenches  and  strains.  It  is  important  to 
recollect  that  although  the  cord  itself  ends  at  the 
spot  indicated,  the  dura  mater,  the  arachnoid, 
and  the  collection  of  cerebro-spinal  fluid  extend 
as  far  as  the  third  piece  of  the  sacrum  (Fig.  135). 
Injuries  inflicted,  therefore,  upon  the  spine  as 
low  downas  this  latter  point  may  cause  death  by 
inducing  inflammation  of  the  meninges.  The  cord 
in  the  dorsal  region  measures  about  10  mm.  from 
638 


Chap.  XXVII I 


SPINAL    CORD 


639 


side  to  side,  and  8  mm.  in  the  anteroposterior 
direction.  The  cervical  enlargement  is  largest 
opposite  the  fifth  or  sixth  cervical  vertebra,  where 
it  measures  about  13  mm.  from  side  to  side. 
The  greatest  part  of  the  lumbar  enlargement  is 
opposite  the  twelfth  dorsal  vertebra,  where  its 
lateral  measurement  is  about  12  mm. 


■Int.  Art. 


Fig.  134, — Section   through  spinal  cord,    membranes,  and 
spinal  canal, 

a.r.,  at  origin  of  anterior  root ;  p.r.,  at  origin  of  posterior  root ;  s.p., 
septum  posticum  ;  p.m.,  pia  mater;  l.d..  ligamentum  denticu- 
latum.  The  arachnoid  (arach.),  dura  mater  (dura  m.),  and  sub- 
arachnoid space  are  shown. 

The  spinal  dura  mater  is  a  strong  and  sub- 
stantial membrane,  and  between  it  and  the  walls 
of  the  vertebral  canal  a  considerable  space  exists, 
occupied  by  loose  areolar  tissue  and  a  plexus  of 
veins  (Fig.  134).  It  is  tough,  and  may  remain 
undamaged  when  the  cord  is  completely  severed 
by  a  crushing  force.  It  will  be  readily  understood 
that  injury  and  inflammation  of  the  meninges,  as 


640  THE    SPINE    AND    SPINAL    CORD        [Chap. 

results  of  lesions  applied  to  the  spine,  are  much 
less  frequent  than  are  like  complications  after 
injuries  to  the  skull.  The  looseness  of  the  spinal 
dura  mater,  its  freedom  from  any  but  slight  and 
occasional  attachments  to  the  bone,  and  the  space 
around  it  in  which  effusions  can  extend  with  little 
possibility  of  becoming  limited,  will  explain  the 
rarity  in  the  spine  of  those  complications  which 
follow  upon  depressed  bone  and  extravasations  of 
pus  and  blood  in  connexion  with  the  cfura  mater 
within  the  skull.  The  plexus  of  thin-walled  veins 
that  occupies  the  interval  between  the  theca  and 
the  bones  may  prove  a  source  of  extensive  haemor- 
rhage in  cases  of  injury  to  the  column.  The  blood 
so  poured  out  tends  to  gravitate  to  the  lowest  part 
of  the  canal,  and  when  sufficient  in  quantity 
may  produce  pressure  effects  upon  the  medulla 
spinalis. 

Over  the  arches  at  the  posterior  aspect  of  the 
vertebrae  is  situate  a  plexus  of  vessels  (the  dorsal 
spinal  veins)  that  receives  blood  from  the  muscles 
and  integuments  of  the  back.  These  vessels  com- 
municate through  the  ligamenta  subllava  with  the 
venous  plexuses  within  the  spinal  canal,  and  by 
means  of  this  communication  inflammation  from 
without  may  be  conducted  to  the  theca  of  the 
cord.  Thus  spinal  meningitis  has  followed  upon 
deep  bed-sores,  and  upon  suppurative  affections 
situated  in  the  immediate  vicinity  of  the  spinal 
laminae. 

Within  the  dura  mater  are  two  spaces,  the 
subdural  and  the  subarachnoid,  as  in  the  skull 
(see  p.  34).  The  arachnoid  is  closely  applied 
to  the  dura  mater,  the  subdural  being  merely  a 
potential  space,  while  the  subarachnoid  is  exten- 
sive (Figs.  134  and  135),  and  occupied  by  cerebro- 
spinal fluid  which  surrounds  the  cord,  and  is 
continuous  with  the  great  subarachnoid  spaces 
at  the  base  of  the  brain  (Fig.  9,  p.  35).  By 
means  of  this  open  communication  inflammatory 
affections  may  readily  spread  from  the  cord  to 
the   brain.      Into  thesa   spaces  blood  may  be  ex- 


XXVII] 


LUMBAR    PUNCTURE 


641 


UBARACnnOiD  5PACfe 


travasated    in    cases    of    injury.      Instances    have 
been   recorded  where   the   theca  has  been   opened 
by    a    wound,    and    the    cerebro-spinal    fluid   has 
escaped  in  large  quantities.     The  fluid  normally 
contains  0*05  per  cent,  of  albumin,  but  if  the  mem- 
branes are  inflamed  the  percentage  may  be  double 
that  amount.     In  certain  conditions  the  pressure 
of  the  fluid  may  rise 
to   such   an   extent   as 
to     cause     death.      In 
normal  conditions  the 
fluid    is    absorbed    at 
any      pressure      above 
that  of  the  surround- 
ing veins   (Hill).     In 
the  recumbent  posture 
the     pressure     should 
support    a    column    of 
water    2    inches    high. 
In      disease     it     may 
rise  to  ten  times  that 
amount.    The  pressure 
may    be    relieved    by 
a     lumbar     puncture, 
made   by   thrusting    a 
needle    8-10   cm.    long 
into  the  subarachnoid 
space    in    the    lumbar 
region    of    the    spine. 
A    point    is    selected 
between  the  third  and 
fourth  lumbar  spines, 
exactly  in  the  middle 
line,    because    here    the    interlaminar    spaces    are 
widest  and  the  danger  of  wounding  blood-vessels 
and  nerve-roots  is  less  than  if  a  lateral  point  is 
selected.      The    interlaminar    space    is    much    in- 
creased  when   the   spine   is   bent   forwards.      The 
needle  perforates  the  ligamentum  subflavum  be- 
tween the  laminae.    Convulsions  follow  if  the  pres- 
sure be  reduced  much  below  the  normal.     At  this 
level  the  cord  cannot  be  injured,  but  the  needle 
v 


Fig.  135.  —  Vertical  section 
of  the  lower  part  of  the 
spinal  column  to  show  the 
position  and  extent  of  the 
subarachnoid  space. 

The  arrow  shows  the   point  for 
lumbar  puncture. 


642 


THE    SPINE    AND    SPINAL    CORD        [Chap. 


I —  Dura  Mater 


Subarach.  Space 
Filum  Terminale 


may  pierce  one  of  the  lower  nerve-roots,  giving 
rise  to  twitching  in  some  of  the.  muscles  of  the 
lower  extremity.  The  injection  of  stovaine  or 
allied  substances  into  the  subarachnoid  space  to 
produce  spinal  analgesia  is  performed  at  the  same 
point  as  lumbar  puncture.  The  injection  should 
not  be  made  until  the  cerebro-spinal  fluid  escapes 
freely  from  the  cannula  when  the  trocar  is  with- 
drawn, for  unless  this  occurs  the  cannula  is  not 
yet  within  the  subarachnoid  space.  Mr.  Barker 
has  pointed  out  that  the 
lowest  part  of  the  sub- 
arachnoid space  when  the 
body  is  supine  is  that 
situated  in  the  mid-dorsal 
region,  and  that  there- 
fore a  fluid  which  is  of 
greater  specific  gravity 
than  that  of  the  cerebro- 
spinal fluid  (1007)  will 
tend,  if  injected  in  the 
lumbar  region,  to  gravi- 
tate to  that  part.  By 
raising  and  lowering  the 
patient's  shoulders  the 
rate  of  diffusion  of  the 
anaesthetic  can  be  regu- 
lated to  a  considerable 
degree.  Injections  have 
also  been  made  in  the 
upper  dorsal  and  cervi- 
cal regions  through  the  interlaminar  spaces,  the 
spine  being  bent  to  extend  these  to  their  greatest 
width. 

The  position  of  the  cord  is  such  that  it  is  not 
readily  reached  in  incised  and  punctured  wounds. 
The  only  spots  at  which  it  is  easy  of  access  are  the 
intervals  between  the  atlas  and  occiput  and  the 
atlas  and  axis.  Many  cases  have  been  recorded  of 
fatal  wound  of  the  cord  in  these  positions.  Lower 
down  in  the  column  the  medulla  spinalis  may  be 
reached  if  the  wound  have  a  certain   direction. 


Fig,  136.  —  Diagrammatic 
vertical  section  of  the 
conus  medullaris,  filum 
terminale,  and  spinal 
membranes. 


XXVII]  WOUNDS    OF    SPINAL    CORD  u:$ 

Thus  a  case  is  reported  where  a  pointed  body 
entered  the  canal  between  the  9th  and  10th  dorsal 
vertebrae,  having  been  introduced  from  below 
upwards. 

Several  examples  of  damage  to  the  cord  by 
sword  or  bayonet  wounds  have  been  put  on  record, 
but  in  most  of  these  instances  the  wound  was 
associated  with  some  fracture  of  the  protecting 
bone. 

The  pia  mater  forms  a  strengthening  sheath 
for  the  cord.     On  it  the   arteries  ramify  before 


Cauda  Equina 
Conus  Medullaris 
Dura   Mater 
Arachnoid 

4th  Lumbar 


Fig.   137. — Transverse  section  of  cauda  equina  and  mem- 
branes at  the  level  of  the  4th  lumbar  vertebra. 

entering  to  supply  its  substance.  The  vertebral, 
intercostal,  lumbar,  ilio-lumbar,  and  lateral 
sacral  arteries  send  twigs  along  the  nerve-roots 
to  the  cord. 

Concussion  of  the  cord.— After  certain  in- 
juries to  the  back  a  train  of  symptoms,  usually 
of  a  severe  and  complicated  character,  has  been 
described  and  assigned  to  a  concussion  or  shaking 
of  the  spinal  cord. 

In  these  injuries  it  is  assumed  that,  as  a  result 
of  a  sudden  shock  transmitted  to  it,  the  cord 
undergoes  certain  molecular  changes,  which  lead  to 
a  more  or  less  severe  disturbance  of  its  function ; 


044  THE    SPINE    AND    SPINAL    COED       [Chap. 

and  the  condition  has  been  compared  to  concus- 
sion of  the  brain,  although  it  must  be  admitted 
that  the  symptoms  often  accredited  to  concussion 
of  the  cord  have  a  character  more  complex  than 
those  seen  in  like  lesions  of  the  more  complex 
organ. 

A  great  many  surgeons  are  inclined  to  dispute 
the  existence  of  this  lesion,  or  rather  decline  to 
recognize  the  connexion  between  a  certain  train 
of  symptoms  and  a  simple  molecular  disturbance 
of  the  cord.  i  It  is  very  probable  that  in  many  of 
the  reputed  instances  of  cord-concussion  the  symp- 
toms (if  we  except  such  as  are  assumed  and  such 
as  depend  upon  changes  in  the  brain)  are  due  to 
a  more  distinct  damage  to  the  medulla  spinalis, 
to  haemorrhages,  to  pressure,  and  to  other  gross 
changes.  Without  entering  into  any  discussion 
upon  the  subject,  it  may  be  sufficient  to  point  out 
some  of  the  anatomical  objections  that  appear  to 
oppose  themselves  to  the  common  conception  of 
concussion  of  the  cord.  The  spinal  cord  is  swung 
or  suspended  in  its  bony  canal,  and  is  separated 
from  the  walls  of  that  canal  on  all  sides  by  a  con- 
siderable interval.  It  is,  indeed,  only  Tield  in 
position  by  the  nerve  trunks  that  pass  out  from 
it  through  the  intervertebral  foramina,  and  by 
its  connexions  with  the  theca.  Above,  it  is  con- 
nected with  that  part  of  the  brain  that  lies 
upon  the  largest  intracranial  collection  of  cerebro- 
spinal fluid  (p.  35),  and  it  would  appear  that 
the  most  violent  movements  possible  of  the  brain 
within  the  skull  could  be  but  very  feebly  communi- 
cated to  the  spinal  cord.  The  cord,  moreover, 
within  its  theca,  is  surrounded  on  all  sides  by  a 
space  occupied  by  cerebro-spinal  fluid.  It  is  diffi- 
cult to  understand,  therefore,  how  a  structure  so 
protected  can  be  so  violently  disturbed  by  a  shock 
received  upon  the  body  as  to  undergo  a  grave  and 
progressive  loss  of  function.*  The  cord  is,  indeed, 
somewhat  in  the  position  of  a  caterpillar  sus- 
pended by  a  thread  in  a  phial  of  water.  It  would 
probably  be  difficult  permanently  to  disturb  the 


XXVII]       CONTUSION    OF    SPINAL    CORD  G45 

internal  economy  of  such  an  insect  (even  if  it  had 
a  structure  as  elaborate  as  the  cord)  by  other  than 
violence  that  would  be  comparatively  excessive. 
Contusion  and  crushing:  of  the  cord.— As 

has  already  been  observed,  the  gravity  of  frac- 
tures and  dislocations  of  the  spine  depends  upon 
the  extent  of  the  damage  received  by  the  cord.  In 
these  accidents  it  is  very  usual  for  some  part 
of  the  injured  vertebra  to  be  projected  into  the 
spinal  canal,  so  as  to  press  upon  or  actually  crush 
the  delicate  nerve  centre  that  it  contains. 

It  is  needless  to  observe  that  the  cord  is  ex- 
tremely soft,  and  thus  it  happens  that  it  may  be 
entirely  broken  up  by  violence  without  the  mem- 
branes being  perceptibly  damaged.  Indeed,  in 
fracture-dislocations  it  is  unusual  for  the  theca 
to  be  torn,  and  it  is  possible  for  the  cord  to  be 
quite  crushed  at  some  one  spot  without  the  corre- 
sponding membranes  being  in  any  way  lacerated. 
The  amount  of  damage  inflicted  upon  the  cord 
will  vary,  of  course,  with  the  magnitude  of  the 
accident;  but,  other  things  being  equal,  it  will 
be  found  to  be  more  severely  injured  in  fracture- 
dislocations  of  the  cervical  and  dorsal  segments 
than  in  like  lesions  in  the  lumbar  spine.  In  the 
atlanto-axial  region  the  amount  of  displacement 
that  follows  upon  luxation  of  the  two  bones  from 
one  another  is  such  that  the  cord  is,  as  a  rule, 
severely  crushed,  and  death  ensues  instantaneously, 
as  is  seen  in  cases  of  death  by  hanging.  In  the 
cervical  and  upper  dorsal  segments  of  the  column 
the  vertebral  bodies  are  small,  the  spine  is  mobile, 
the  fractures  met  with  in  these  parts  are  usually 
due  to  indirect  violence,  and  are  associated  with 
much  displacement.  In  the  lower  dorsal  region, 
again,  the  greater  rigidity  of  the  spine  renders 
any  displacement,  when  it  does  occur,  likely  to  be 
considerable.  In  the  lumbar  region,  on  the  other 
hand,  it  must  be  noted  that  the  cord  only  ex- 
tends to  the  lower  border  of  the  1st  vertebra.  The 
bodies  of  the  vertebrae,  also,  in  this  district,  are 
very   large   and   cancellous,    and   can    undergo    a 


040  THE    SPINE    AND    SPINAL    COED       LChap. 

severe  amount  of  crushing  without  a  correspond- 
ing degree  of  displacement  being  produced.  The 
part,  too,  is  well  protected  by  the  large  inter- 
vertebral discs,  and  by  the  immense  masses  of 
muscle  that  surround  the  spine  in  the  loins.  Such 
portion  of  the  spinal  cord  as  extends  into  the 
lumbar  region  is  protected  also  by  the  many  cords 
of  the  cauda  equina,  which,  by  their  looseness 
and  comparative  toughness,  tend  to  minimize  the 
effects  of  violence. 

The  degree  of  displacement  of  bone  required  to 
produce  pressure  effects  upon  the  cord  is  often 
greater  than  would  be  supposed.  At  post-mortem 
examinations  portions  of  injured  vertebrae  have 
been  found  encroaching  upon  the  spinal  canal  to 
a  considerable  extent  in  cases  where  no  evidences 
of  damage  to  the  cord  existed  during  life.  Dr. 
J.  W.  Ogle  reports  the  case  of  a  man  who,  after 
an  injury  to  the  neck  from  a  fall,  presented  no 
spinal  symptoms  until  three  days  had  elapsed. 
He  ultimately  became  paralysed,  and  died  thirty 
two  days  after  the  accident.  The  autopsy  revealed 
a  dislocation  forwards  of  the  6th  cervical  vertebra, 
of  such  an  extent  that  the  body  below  projected 
at  least  J  an  inch  into  the  spinal  canal. 

The  remarkable  manner  in  which  the  cord  will 
accommodate  itself  to  a  slowly  progressing  pres- 
sure is  often  well  seen  in  the  results  of  chronic 
bone  disease  in  the  column. 

The  symptoms  due  to  injury  to  the  cord  and  to 
the  nerves  contained  in  the  spinal  canal  will  ob- 
viously depend  upon  the  situation  and  extent  of 
the  lesion.  The  diagnosis  of  the  situation  of  the 
lesion  is  complicated  by  the  relation  the  nerves 
bear  to  the  various  vertebrae,  and  by  the  fact  that 
the  majority  of  the  great  trunks  arise  from  the 
cord  at  a  spot  above  the  point  at  which  they 
issue  from  the  vertebral  canal.  The  two  highest 
nerves,  the  1st  and  2nd  cervical,  pursue  an  almost 
hcrizontal  course  in  their  passage  from  the  cord 
to  their  points  of  exit  from  the  canal.  The  re- 
maining  nerves   take   a   more   and   more   oblique 


XXVII]         CRUSHING    OF    SPINAL    COKT)  647 

direction,  until  at  last  the  lowest  nerve  trunks  run 
nearly  vertically  downwards  as  they  pass  to  their 
respective  intervertebral  foramina. 

Points  of  exit  of  nerves  from  the  vertebral 
canal. — The  1st  cervical  nerve  leaves  the  canal 
above  the  1st  cervical  vertebra.  The  remaining 
cervical  trunks  escape  also  above  the  vertebrae 
after  which  they  are  named,  the  8th  cervical 
nerve  leaving  the  canal  between  the  last  cervical 
and  the  1st  dorsal  vertebrae.  The  dorsal,  lumbar, 
and  sacral  nerves  have  their  points  of  exit  below 
the  vertebrae  after  which  they  are  named.  Thus, 
the  1st  dorsal  nerve  will  pass  through  the  fora- 
men between  the  1st  and  2nd  dorsal  vertebrae, 
and  so  on. 

Points  of  Origin  from  the  Cord 

The  1st  cervical  nerve  arises  from  the  cord  opposite  the  interval 

between  the  atlas  and  occiput. 
The  2nd  and  3rd  cervical  nerves  arise  from  the  cord  opposite  the 

axis. 
The  4th,  5th,  Gth,  7th,  and  8th  cervical  nerves  arise  from  the  cord 

opposite  the  3rd,  4th,  5th,  Gth,  and  7th  vertebrae  respectively. 
The  first  four  dorsal  nerves  arise  from  the  cord  opposite  the  discs 

helow  the  7th   cervical   and  the   1st,    2nd,    and  3rd   dorsal 

vertebrae  respectively. 
The  5th  and  6th  dorsal  nerves  arise  from  the  cord  opposite  the 

lower  borders  of  the  4th  and  5th  vertebrae. 
The  remaining  six  dorsal  nerves  arise  from  the  cord  opposite  the 

bodies  of  the  6th,  7th,  8th,  9th,  10th,  and  11th  vertebrae. 
The  first  three  lumbar  nerves  arise  from  the  cord  opposite  the 

12th  dorsal  vertebra. 
The  4th  lumbar  nerve  arises   from   the    cord   opposite   the   disc 

between  the  12th  dorsal  and  1st  lumbar  vertebrae. 
The  last  lumbar  nerve,  together  with  the   sacral   and  coccygeal 

nerves,  arises  from  the  cord  opposite  the  1st  lumbar  vertebra. 

It  will  be  seen,  therefore,  that  in  noting 
the  symptoms  due  to  crushing  of  the  entire  nerve 
contents  of  the  vertebral  canal  at  a  certain  spot, 
consideration  must  be  taken,  not  only  of  the  effects 
of  damaging  the  medulla  at  that  point,  but  also  of 
the  result  of  lacerating  nerve-trunks  that  may 
issue  there,  although  their  origins  are  above  the 
seat  of  lesion.     The  cord  is  also  very  often  only 


G48  THE    SPINE    AND    SPINAL    CORD        [Chap. 

damaged  in  part,  or  it  may  entirely  escape,  while 
one  or  more  nerves  are  crushed  by  the  fractured 
vertebrae  or  by  fragments  of  bone  separated  by 
the  lesion. 

In  fractuie-dislocations  the  upper  vertebral 
body,  as  already  stated,  usually  glides  forward, 
with  the  result  that  the  anterior  and  antero- 
lateral parts  of  the  cord  are  brought  into  violent 
contact  with  the  projecting  border  of  the  ver- 
tebra below  the  seat  of  lesion. 

It  is  in  these  parts  of  the  cord  that  the  main 
motor  tracts  run,  and  thus  it  happens  that  motion 
is  more  often  lost  in  the  parts  below  the  site  of 
the  injury  than  is  sensation.  If  there  be  partial 
motor  and  sensory  paralysis,  the  disturbance  of 
the  former  function  is  likely  to  be  in  excess  of 
that  of  the  latter.  In  no  case,  indeed,  does  there 
appear  to  have  been  a  loss  of  sensation  without,  at 
the  same  time,  some  disturbance  in  the  powers  of 
movement.  If  the  grey  matter  of  the  cord  be  not 
severely  damaged,  reflex  movements  appertaining 
to  that  segment  of  the  cord  can  usually  be  induced 
in  the  paralysed  parts  by  proper  stimulation.  If 
those  reflex  movements  be  lost,  it  may  be  inferred 
that  the  grey  matter  is  broken  up,  and  that  the 
entire  spinal  medulla  has  been  crushed  at  the  seat 
of  lesion.^ 

The  higher  up  the  fracture  in  the  column  the 
greater  is  the  tendency  for  the  function  of  respira- 
tion to  be  interfered  with.  If  the  lesion  be  at  the 
upper  end  of  the  dorsal  spine,  then  not  only  will 
all  the  abdominal  muscles  be  paralysed,  but  also 
all  the  intercostals.  A  fracture  associated  with 
injury  to  the  cord,  when  above  the  4th  cervical 
vertebra,  is,  as  a  rule,  instantaneously  fatal. 
The  phrenic  nerve  comes  ^  off  mainly  from  the 
4th  cervical  nerve,  receiving  contributions  also 
from  the  3rd  and  5th.  The  4th  nerve  issues  just 
above  the  4th  cervical  vertebra.  If  the  cord  be 
damaged  immediately  below  this  spot,  the  patient 
can  breathe  only  by  means  of  the  diaphragm ; 
and  if   the   lesion   be   so  high   as  to    destroy   the 


XXV11]  INJURY    TO    SPINAL    CORD  649 

main  contribution  to  the  phrenic,  respiration  of 
any  kind  becomes  impossible. 

Certain  disturbances  of  micturition  are  fre- 
quent in  cases  of  injury  to  the  cord.  The  re- 
flex centre  for  this  act  is  lodged  in  the  lumbar 
enlargement.  The  irritation  of  the  vesical  walls, 
produced  by  the  increasing  distension  of  the 
bladder,  provides  the  needful  sensory  impulse. 
This  impulse  is  reflected  to  the  nerves  controlling 
the  bladder  muscles,  and  especially  to  the  detrusor 
urinse,  and  by  their  contraction  the  organ  is 
emptied  (p.  470).  The  action,  however,  can  be 
to  some  extent  inhibited  by  influences  passing 
down  from  the  brain  to  the  lumbar  centre,  and  the 
tendency  to  a  frequent  discharge  of  urine  is  re- 
sisted by  contraction  of  the  sphincter.  When, 
therefore,  any  part  of  the  cord  between  the 
lumbar  centre  and  the  brain  is  damaged,  inhi- 
bition can  have  no  effect.  Immediately  after 
the  accident  the  temporary  suspension  of  reflex 
actions  from  shock  produces  some  retention  of 
urine,  and  after  that  the  bladder  empties  itself  at 
frequent  intervals,  the  patient  being  unconscious 
of  the  act  and  unable  to  influence  it. 

If  the  centre  itself  be  damaged  in  the  lumbar 
cord,  the  patient,  after  a  little  retention,  will 
suffer  from  absolute  incontinence ;  and  a  like 
result  will  follow  if  the  nerve  connexions  between 
the  cord  and  bladder  below  the  spinal  centre  have 
been  destroyed.  The  principal  nerves  connecting 
the  medulla  spinalis  with  the  bladder  are  the 
3rd  and  4th  sacral. 

The  act  of  defalcation  also  is  apt  to  be  dis- 
turbed in  a  like  manner.  Here  there  is,  as  in  the 
previous  case,  a  reflex  centre  in  the  lumbar  en- 
largement, with  motor  and  sensory  nerves  connect- 
ing it  below  with  the  rectum  and  its  muscles ;  and 
also  between  this  centre  and  the  brain  are  tracts, 
but  little  known,  along  which  inhibitory  actions 
can  extend. 

When  the  centre  itself  is  damaged,  or  the  con- 
nexion severed  that  unites  it  with  the  viscus,  the 
v* 


650  THE    SPINE    AND    SPINAL    CORD       [Chap. 

patient  will  suffer  from  incontinence  of  faeces  and 
will  be  unable  in  any  way  to  control  the  act. 
When  the  cord  is  damaged  at  any  spot  between  the 
centre  and  the  brain,  then  the  act  of  defsecation 
will  be  performed  at  regular  intervals,  without 
either  the  patient  being  conscious  of  the  act  or 
being  capable  of  inhibiting  it. 

In  some  injuries  to  the  cervical  cord  tho 
patient  has  suffered  from  severe  vomiting  for  some 
time  after  the  accident,  or  has  exhibited  a  remark- 
able alteration  in  the  action  of  his  heart.  Mr. 
Erichsen,  for  example,  reports  the  case  of  a  man 
who,  after  a  severe  blow  upon  the  cervical  spine, 
continued  to  vomit  daily  for  several  months.  In 
the  other  category,  instances  have  been  recorded 
where  the  pulse  has  sunk  as  low  as  48,  or  even 
36  or  20,  after  lesions  to  the  column  in  the  neck. 

These  changes  are  supposed  to  be  due  to  dis- 
turbance of  the  vagus,  and  it  is  further  suggested 
that  the  morbid  influence  is  conveyed  to  the  vagus 
by  the  spinal  accessory  nerve  with  which  it  is  so 
freely  associated. 

It  should  be  remembered  that  the  spinal  acces- 
sory trunk  has  origin  from  the  cord  as  low  down 
as  the  6th  or  7th  cervical  nerves.  Some  details 
concerning  the  position  of  centres  in  the  spinal 
cord,  connected  with  areas  of  skin,  groups  of 
muscles,  and  viscera,  have  been  given  already  when 
dealing  with  the  nerve  supplies  of  the  extremities 
and  abdomen   (see  pp.   346  and  625). 

Spina  bifida.  —  This  term  refers  to  certain 
congenital  malformations  of  the  vertebral  canal 
associated  with  the  protrusion  of  some  of  its  con- 
tents in  the  form  of  a  fluid  tumour.  The  mal- 
formation usually  consists  in  an  absence  of  the 
neural  arches  and  spines  of  certain  of  the  verte- 
brae, and  the  tumour  therefore  projects  pos- 
teriorly. Spina  bifida  is  most  common  in  the 
lumbo-sacral  region,  the  neural  arches  of  the  last 
lumbar  and  of  all  the  sacral  vertebrae  being  ab- 
sent. In  development  the  neural  arches  close  first 
in  the  dorsal  and  last  in  the  lumbo-sacral  region. 


XX  VIII  MENINGO-MYELOCELE  651 

Next  in  frequency  it  is  found  limited  to  the 
sacral  region.  It  is  rare  elsewhere.  (1)  The 
membranes  may  protrude  alone  {spinal  meningo- 
cele). (2)  The  membranes  may  protrude  together 
with  the  spinal  cord  and  its  nerves  (meningo- 
myelocele). (3)  The  membranes  may  protrude 
with  the  cord,  the  central  canal  of  which  is 
dilated,  so  as  to  form  a  sac-like  cavity  (syringo- 
myocele).     (See  Figs.   135  and  136.) 

The  meningo= myelocele  is  the  most  common 
form.  The  first-named  variety  is  rare,  the  last- 
named  very  rare.  When  the  cord  occupies  the  sac 
it  usually  adheres  to  its  posterior  wall,  the  nerves 
running  transversely  across  the  sac  to  reach  the 
intervertebral  foramina.  When  compressed,  the 
cerebro-spinal  fluid  is  forced  into  the  subarach- 
noid spaces  at  the  base  of  the  brain,  which  is 
forced  upwards  against  the  anterior  fontanelle, 
where  its  impact  may  be  felt.  The  tumour  be- 
comes enlarged  and  tense  when  the  child  cries. 
The  distension  of  the  cerebral  and  spinal  veins 
forces  the  fluid  in  the  direction  of  least  resistance. 

As  might  be  expected,  spina  bifida  is  very  com- 
monly associated  with  some  evidence  of  injury 
to  the  nerves  arising  from  the  lower  part  of  the 
spinal  cord.  The  defect  occurs  at  an  extremely 
early  stage  of  development,  and  hence  part  of 
the  cord  or  of  the  nerves  in  the  region  of  the 
tumour  may  be  absent  or  defectively  developed. 
In  some  cases  the  nerve  affection  takes  the  form 
of  club-foot  of  a  severe  grade.  In  other  instances 
there  is  more  or  less  complete  paralysis  of  the 
lower  limbs,  bladder,  and  rectum. 

Operations  upon  the  cord. —Sir  Victor 
Horsley  and  others  have  cut  down  upon  the 
spine  and  removed  a  tumour  from  the  spinal  cord 
with  perfect  success,  and  with  relief  to  the  symp- 
toms from  which  the  patient  was  suffering.  The 
spinal  canal  has  also  been  exposed  in  certain  cases 
where  callus  in  an  old  fracture  of  the  spine  was 
pressing  upon  the  cord,  or  where  a  small  osseous 
growth  was  encroaching  on  the  canal. 


INDEX 


Abces  en  bissac,  592 

•  en  bouton  de  chemise.  592 

Abdomen,  332 

■ •  abscess  of,  342 

•  blood-vessels   of,  335,   343, 

442 

■  blows  on,  337 

congenital  deformities  of. 

349 

connective  tissue  of,  342 

■  fascia  of,  336 

■  lymphatics  of,  344 

muscles  of,  341 

■  nerves  of,  344 

■  parietes  of,  332,  335,  366 

— — •  skin  of,  335 

surface  anatomy  of,  332 

■ tension  or  pressure  with- 
in. 359 

■ •  wounds  of,  342 

Abdominal  aorta,  335 

" ■  belt,"  336 

- — ■  connective  tissue  and  ab- 
scesses, 342 

- — ■  rings,  351,  354 

■  viscera,  371 

• >  nerve  supply  of,  440 

■ • support  of,  380 

■ ■  surface  markings  of, 

378 

Abscess,  alveolar,  142 

■ .  axillary,   244 

- — -  cerebral,  11 

■ ■  •  trephining  for,  9 

• ■  cervical,  174 

•  gluteal,  505 

• hepatic,  418 

• ■  iliac,  342,  367,  368 

>  in  antrum,  114 

■  in  hip-joint,  518 

■ in  scalp.  6 

• ■  in  temporal  fossa,  8 

■  intercostal,   209 

intracranial,  10 

! ■  ischio-rectal,   458 


Abscess,  lumbar,  367,  370 

— —  mediastinal,  221 

— -  of  abdominal  parietes,  342 

—  of  Bartholin's  gland,  489 
of  mastoid  cells,  91 

■ ■  orbital,  54 

■  palmar,  311 

■  parotid,  129 

■  pelvic,   518 

•  peri  nephritic,  430 

«  plantar,  592 

«  popliteal.  554 

■  postpharyngeal,   160 

■  prostatic,  475 

■ •  psoas,  368,  513 

—  renal,  431 

retropharyngeal,  368 

subfascial,  353 

temporo-sphenoidal,  10 

thecal,  314 

•  typhlitic,  400,  401 

Accessory    glands    of    tongue, 
151 

•  sinuses,  110 

Acetabulum,  445,  518 

■  fractures  of,  445 

"  Aching  legs,"  580 
Acne  hypertrophica,  98 
Acromegaly,  39 
Acromio-clavicular   joint,   225, 
237 

■ dislocations  of,  238 

■ ■  movements  of,  237 

Acromio-thoracic    artery,    226, 

228 
Acromion  process,  224 

■ fracture  of,  240 

Adductor  longus  muscle,   511, 

514 
—  magnus  tubercle,  549 
Adenoids,  159 
Agatz's  plate,  617 
Air  in  veins,  195,  247 
Air-passages,     foreign    bodies 

in,  187 


653 


654 


SURGICAL   APPLIED    ANATOMY 


Air-sac   in  neck,  202 
"  Alderman's  nerve,"  86 
Alimentary     canal,     rate     of 

progress    of    contents    of, 

403 
Alveolar    abscesses    of    teeth, 

142 
Ampulla  of  Vater,  420,  425.  426 
Amputation        (sec        various 

bones  and  joints) 
Anal  canal,  491 

mucous       membrane 

of,  497,  498 

■ ■  triangle,  455 

■  valves,  497 

Anastomosis,  abdominal,  442 

—  intestinal,  397,   412 
Anastomotica  magna,  551 
Aneurysm,  aortic,  195.  442 
— —  arterio-venous,   56 
■  gluteal,  507 

■  in  axillary  artery,  247 

—  in  neck,  195 

.  of  femoral  artery,  515 

of  posterior  tibial  artery, 

579 

■  popliteal,  556 

■ traumatic,  56 

Ankle,  587 

— •  bony  points  of,  587 

•  fascia  of,  591 

skin  of,   590 

—  sprains  of,  593 

■  subcutaneous    tissue     of. 

590 

■  surface  anatomy  of,  587 

tendons  of,  588,  595 

Ankle-joint.  588,  597 

amputation  at,  617 

■  disease  of,  598 

■  dislocations  of,  599 

■  fractures   about,   599 

— — •  nerve  supply  of,  599 

—  vessels  of,  589 
Annular    ligament    of    ankle, 

592 

•  ■  of  wrist,  311 

Ano,  fistula  in,  458 
Anosmia,  109 

Anterior  crural  nerve,  516,  621 
■  nares,  100 

superior  spine,  333 

Anticlinal   spine,  215 
Antrum,  mastoid,  91 

•  of  Highmore,  113 

Anus,  497 

■  imperforate.   498 

nerves  of.  500 

■  ulcers  of,  497 


Aorta,  abdominal,  335,  442 
— -  thoracic,  195 
Apical  point  of  thorax,  218 
Aponeurosis  (see  Fascia) 
Appendicitis,  401 
Appendicostomy,  411 
Appendix,  400 
■  length  of,  400 

—  lymphatics  of,  401 

mesentery  of,  401 

•  position  of,  400 

Aqueduct  of  Fallopius,  90 
Aqueous  humour,  71 
Arachnoid,  34.  640 

Arcuate  tendon  of  levator  ani, 

452 
Arcus  senilis,  61 
Arm,  264 

■  amputation  of.  270 

■  epiphyses  of,  331 

— —  fascia  of,  265 

lymphatics  of,  278 

muscles  of,  325 

■  nerves  of,  265,  324 

■  skin  of,  265 

■  surface  anatomy  of,  264 

Arnold's  nerve,  85 

Arteries     (see     Axillary,    etc., 

and  Blood-vessels) 
Arterio-venous  aneurysms,  56 
Arthrectomy,  575 
Aryteno-epiglottic    folds,    159, 

180 
Ascaris  lumbricoides,  392 
Ascending  colon,  405 
Astragalo-scaphoid  joint.  588 
Astragalus,  dislocation  of,  606 

■  fracture  of,  614 

Atlanto-axial  region  of  spine, 

632 
Atlas,   159 

Attic  of  tympanum,  88,  91 
Auditory   meatus,   external,  83 
Auricle  (see  Ear) 
Auricles,  supernumerary,  202 
Auricular  nerve,  169 
Avulsion  of  fingers,  323 
Axilla,  227,  242 

—  fasciae  of,  243 

lymphatic  glands  of,  245 

relations  of,  243 

Axillary  artery,  227 

■  aneurysm  of,   247 

•  ■  ligature  of,  248 

•  ■  relations  of,  243 

•  glands,  198,  212,  227 

—  removal  of,  246 

—  nerves,  249 
■  region,  abscess  of,  244 


INDEX 


655 


Axillary  vessels,  246 

. .  ■  wounds  of,  247 

Axis,  159 

Azygos  veins,  222 

Barbadoes  leg.  518 
Bartholin's  duct,  144 

.  gland,  488 

•  abscess  of,  489 

Basal  ganglia,  44 
Base  of  condyles  of  humerus, 
fracture  at,  285 

of  skull,  fractures  of,  27 

Basilic  vein,  264 

Bell's  muscle,  471 

Biceps  tendon  in  arm,  253 

■  —  in  ham,  555 

Bicipital  groove,  226 
Bile-duct,  relations  of,  415 

-  rupture  of.  421 
Bladder,  465 

■  cystoscopic     examination 

of,  469,  471 

development  of,  340 

■  distension  of,  466 

■  double,  471 

■  empty,  465 

■  extroversion  of,  350 

fasciculated,  470 

female,  471 

foreign  bodies  in,  472 

■  in  hernise,   467 

- — ■  male,  465 

■  mucous  membrane  of,  469 

■  muscles  of,  471 

muscular  coat  of,  470 

■  nerves  of.  470,  500 

■  of  child,   472 

■  puncture  of,  above  pubes, 

466 
■  — —  per  rectum,  468 

relations      of,     to      peri- 

toneum, 465,  466,  467 

rupture  of,  468 

sacculated,  470 

stone  in,  462 

Blood  tumours  of  scalp,  7 

on  pinna,  85 

Blood-vessels  of  abdomen,  335, 
343,  442 

■ ■  of  ankle,  589 

of  auditory  meatus,  83 

of  axilla.  246 

of  brain,  47 

of  breast,  213 

of  buttocks.    504,   507 

of  elbow,  276 

•  of  eye,  56 

of  eyeball,  64 


Blood-vessels  of  eyelids,  77 

of  foot,  590,  596 

of  forearm,  292 

-  of  gall-bladder,  419 

of  hand,  315 

of  heel,  617 

— —  of  knee,  555 
of  leg,  579 

of  nasal  cavities,   108 

of  neck,  194 

of  orbit,  56 

of  palate,  156,  157 

of  perineum,  456 

of  pinna,  85 

of  rectum,  495 

of  retina,  65,  66 

— —  of  scalp,  13 

'  of  Scarpa's  triangle,  515 

of  spermatic  cord,  487 

of  spinal  cord,  643 

• of  tongue,  148 

of  tonsil,  164 

of  tympanum,  96 

Bones,  nerve  supply  of,  331 
Bony  vault  of  cranium,  17 
Brachial  aponeurosis.  266 

•  artery,  264,  267,  278 

abnormalities  of,  258 

fascia,  266 

plexus,  170,  248 

— — paralysis  of,   328 

relations  of,  243 

Brachialis  anticus,   266 
Brain,  31,  46 

basal  ganglia  of,  44 

«  blood-vessels  of,  47 

cisternae  of,   35 

■ ■  concussion  of,  47 

cortex  of.  45 

fissures  of,  39.  42 

inferior     temporal      con- 
volution of,  44 

injuries  to,  47 

membranes  of.  31 

motor  areas  of,  40,  45 

surface  relations  of.  39 

Branchial  fistuke,  200 
Brasdor's  operation,  194 
Breast  (see  Mamma) 
Bregma,  17 

Broca's  convolution,  43 
Bronchi,     foreign     bodies    in, 

187,  218 
Bronchial    lymphatic    glands, 

192 
Bronchocele,   188 
Brunner's  glands,  395 
Bryant's    method    of   dividing 

muscles  of  palate,  157 


666 


SURGICAL   APPLIED   ANATOMY 


Buccal  cavity,  144 
lymphatics  of,  198 

nerve,  123 

Bulla  ethmoidalis,  106 
Bunions,  594 

Bursas  about  elbow- joint.  279 

about  foot,  594 

about  ham,  557 

about  hyoid,  179 

— —  about  knee,  553,  557 

■ about    Scarpa's    triangle, 

514 

about  shoulder- joint,  252 

- — .  .  relations  of,  250 

— —  over  great  trochanter,  506 
over     ischial     tuberosity, 

507 

patellar,  553 

subacromial,  252 

subpsoal,  514 

Buttocks,  502 

abscess  of,  505 

■  fascia  of,  505 

■ ■  fold  of,  503 

■  nerves  of,  504,  507 

skin  of,  504 

nerve  supply  of,  510 

— —  subcutaneous     fascia    of, 

504 

surface  anatomy  of,  502 

vessels  of,  504,  507 

Caecum,  398 

foreign  bodies  in,  400 

■  hernia  of,  399 

in  intestinal  obstruction, 

400 

lymphatics  of,  401 

movements  of,  400 

opening  of,  411 

■  position  of,  398 

Caesarian  section,  448 
Calcaneo-cuboid  joint,  588 
Calcaneo-scaphoid      ligament, 

610.  611 
Calcar  femorale,  527 

relations  of,  529 

Calyces  of  kidney.  438 
Canal  of  Nuck,  359 

■  of  Schlemm,  72,  73 

Cancer  en  cuirasse,  212 

■ of  breast,  211 

■  of  pylorus,  427 

of  rectum.  496 

-  of  stomach,  223,  388 

of  tongue,  151 

Capsule  of  lens,  70.  72 

of  shoulder-joint,   252 

relations  of,  250 


Capsule  of  Tenon,  52 
Cardiac  orifice,  381,  382 
Caries    of    lumbar    vertebrae. 
370 

of  sternum,  206 

of  teeth,  140 

** sioofL  "  94 

Carotid   artery,   129,    165,    167, 
195 

■ aneurysm  of,  195 

external,  129 

ligature  of,  194 

sheath  of,  174 

tubercle.  165,  195 

Carpo-metacarpal  joint,  318 
Carpus,  fracture  of,  321 
Castration,  476,  483,  487 
Cataract,  70 

Catheterism      of      Eustachian 
tube,  96 

of  urethra,  477 

Cauda      equina      membranes, 

sections  of,  642,  643 
Cavernous  sinus,  33 
Cephalhaematomata,  7 
Cephalic  vein,  273,  276 
Cerebellum,  abscess  of,  11 
lesions  of,  49 

point  for  trephining,  11 

-  tumours  in.  49 
•  veins  of,  49 

Cerebral    abscess,    trephining 
for,  9 

circulation,  36,  47 

•  localization,  45 

•  tumour,    trephining    for, 

Cerebro-spinal    fluid,    37,    638, 
640.  641 

in  cranial  spaces,  35 

Cervical  artery,  169 

resrion  of  spine,  630 

sac,  202 

sinus,  200 

■  sympathetic,  paralysis  of, 

58 

(see  also  Neck) 

Cervico-dorsal  region  of  spine, 

632 
Cervix  uteri.  490 
Check  ligaments,  53 
Cheloid,    sternum    a    frequent 

seat  of,  205 
Chest   (see  Thorax) 
Cholecystectomy,  423 
Cholecystenterostomy,  423 
Cholecystotomy,  422 
Chopart's  operation,  619 
Chorda  tympani  nerve,  96 


INDEX 


657 


Choroid,  62 
Ciliary  muscle,  72 

zone,  65 

Circumcision,  480 

Circumflex     artery,     external, 

rupture  of,  543 
.  internal,    wound    of, 

543 

,  posterior,  229,  251 

.  nerve,  229,  251 

Cirsoid  aneurysm.  13 
Cisternse  of  brain,  35 
Clavicle,  224.  229 

absence  of,  234 

■  dislocations  of,  236,  238 

■  excision  of,  230 

■  fracture  of,  231 

movements  of,  235 

-  ossification  of,  234 
■  relations  of,  228,  233 

resection  of,  230 

Cleft  palate,  153 

"  Clergyman's     sore     throat," 

182 
Club-foot,  608 
Coccygeus,  450 
Coccygodynia,  450 
Coccyx,  450 
Cochin  leg,  518 
Cceliac  axis,  335,  442 
Colectomy,  411 
Colles'  fascia,  459 

fracture,  318 

Colombia  iridis,  64 
Colon,  404 

■  antiperistalsis  in,  493 

— —  ascending,  405 

congenital  malforma- 

tions of,  412 

descending,  405 

!  relations  of,  409 

■  iliac,  405 

■  operations  on,  411 

■  pelvic,  407 

■  stricture  of,  405 

■  transverse,  405 

■  relation  of,  to  liver, 

417 
Colotomy.  iliac,  411 

inguinal,  411 

lumbar,  405 

Commissures  of  prostate,  473 
Concussion  of  brain,  47 

of  spinal  cord,  643 

Condyles    of    humerus,     frac- 
ture at  base  of,  285 

Congenital     absence     of     cla- 
vicle, 234 
of  patella,  569 


Congenital  absence  of  rectum, 
408 

deficiency  of  rectum,  408 

deformities    of    abdomen, 

349 
■  dermoid  cysts,  146 

dislocation  of  hip,  531 

- — -  exomphalos,  349 

•  fistulse,  82,  200 

■  hernia,  339.  351,  358 

— —  malformations     of     anus, 
498 

of  colon,  412 

of  rectum,  498 

thyroid  cysts,  146 

Conjunctiva,  77 

Contusion  of  spinal  cord,  645 

Conus   medullaris   membrane, 

section  of,  642 
Convolution,  Broca's,  43 

inferior  temporal,  44 

Coraco-acromial  ligament,  226 
Coraco-brachialis  muscle,  227 
Coracoid  process,  226 

■ ■ fracture  of,  241 

Cornea,  59 

■  dimensions  of,  59 

nerves  of,  61 

Coronal  structure.  18 
Coronary  artery,  385 
Coronoid  process,  fracture  of, 

288 
Corpus  striatum,  44 
Cortex,  motor  centres  of,  40,  45 
Costo-rectal  point,  380 
Costo-vertebral  ligament,  436 
"  Coup  de  fouet,"  579 
Cowper's  gland,  489 
Coxa  vara,  530 

Cranial    bones,    blood    supply 
of,  5 

necrosis  of,  5 

- — ■  nerves,  57 

spaces     containing     cere- 

brospinal fluid,  35 

Craniectomy,  30 

Cranio-cleido-dysostosis,  234 

Cranio-tabes,  18 

Cranium,  bony  vault  of,  17 

■  {see  also  Skull) 

Cremaster  muscle,  487 

Cremasteric  artery,  487 

Cribriform  plate,  104 

Cricoid  cartilage,  180 

"  Cross-legged  progression," 
525 

Crucial  ligaments  of  knee- 
joint,  558 

Crural  canal,  360 


658 


SURGICAL   APPLIED   ANATOMY 


Crural  canal,  hernia  into,  362 
• relations  of,  362 

nerve,  anterior,  516,  621 

paralysis  of,  621 

sheath,  366 

"  Crutch  paralysis,"  268 
Cuboid    bone,    dislocation    of, 

614 
Cuneiform  bone,  inner,  587 

dislocation       of, 

614 

fracture  of.  614 

Cut  throat,  177 
Cystocele.  vaginal,  489 
Cystoscopic     examination     of 

bladder,  469.  471 
Cysts  in  floor  of  mouth,  146 
■  of  scalp,  2 

Dacryops,  79 

Dartos  tissue,  336 

Deep  sensibility,  124,  330 

Defsecation  in  spinal  injuries, 

649 
Deltoid,  225 

.  muscle,  249,  264 

region,  225,  249 

■  tubercle,  224 

Dermoid  cysts,  congenital,  146 
Descending  colon,  405 
Diaphragm,  416 
Diaphragmatic  hernia,  365 
Diastolic  empty  bladder.  466 
Diploic  veins,  14 
Dislocation  (see  various  bones 

and  joints) 
Divarication  of  recti,  338 
Dorsalis  pedis  artery,  596 

scapulae  artery,  229 

Dorso-lumbar  region  of  spine, 

632 
Dorsum  ilii,  dislocation  upon, 

532,  535 
"  Double-chin,"  170 
Douche,  nasal,  103 
"  Drop-wrist,"  329 
Duodeno-jejunalis    fossa,    394, 

395 
Duodenum,  394 
occlusion  of,  395 

suspensory  muscle  of,  394 

Dupuytren's  contraction.  309 

fracture.  602 

Dura  mater,  31,  639 

Ear,  82 

.  bleeding    from,    in    frac- 
ture of  base  of  akull,  29 

blood  supply  of,  85 


29 


Ear,  blood  tumours  on,  85 

■  coughing,  86 

external,  83 

haematomata  of,  85 

labyrinth  of,  97 

■  lymphatics  of,  198 

- — -  nerve  supply  of,  85 

■  ossicles  of,  88 

sneezing,  86 

watery  discharge  from, 

— —  yawning,  86 
Ecchymosis,  631 

Ectopia  vesicas,  350 
Elbow,  272 

■  dislocations  of.  282 

■  fold  of,  272 

fractures  about,  285 

lymphatic  glands  of,  278 

.  nerves  of,  277,  290 

resection  of,  289 

■  skin  of,  275 

■  surface  anatomy  of,  272 

■  veins  of,  276 

Elbow-joint,  279 

«  bursae  about,  279 

disease  of,  280 

■  ligaments  of,  279 

sprains  of,  280,  285 

Elephantiasis  Arabum,  517 

■  of  scrotum,  483 

Eminentia  articularis,  126 
Emissary  veins  of  skull,  13 
Emphysema.  216 
Encephalocele.  19,  100 
Encysted  hernia,  358 

hydrocele  of  cord,  357 

Enterectomy,  397 
Enterocele,  vaginal,  489 
Enterotomy,  397 
Epicondyle,  fracture  of,  286 
Epicritic  sensibility,  124,  330 
Epididymis,   485 

nerve  supply  of,  486 

Epiphora,  80 

Epiphyseal   line,   relations  of, 

250 
Epiphysis  in  knock-knee,  567 
of    acromion,    separation 

of.  240 
of  clavicle,  separation  of. 

234 
■  of     coracoid,     separation 

of.  241 
• ■  of  femur,    separation    of, 

525,  530,  573 

of     humerus,     separation 

of.  261.  287 

■  of    olecranon,    separation 

of,  288 


INDEX 


6o9 


Epiphysis  of  pelvis,  separa- 
tion of,  448 

of  radius,    separation   of, 

289,  321 

of    tibia,    separation    of, 

574,  584 

•  of  upper  limb,  331 

Epipteric  bone,  21 

Epispadias,  482 

Epistaxis,  108 

Erb's  palsy,  249 

Erector  spinae  muscle,  629 

Erysipelas  of  scalp,  14 

Estlander's  operation,  209 

Ethmoidal  cells,  105 

Eustachian  catheter,  96 

■  tube,  94 

Eversion,  movements  of,  605 

Excision  (see  special  parts) 

Exomphalos,  congenital,  349 

Extensor  brevis  digitorum 
tendon,  589 

communis  digitorum 

muscle,  576 

longus  digitorum  tendon. 

589 
hallucis  muscle,   576, 

577 

tendon.  588 

External  auditory  meatus.  83 
blood  supply  of, 

85 
■ nerve  supply  of, 

85 

carotid  artery.  129 

■  pterygoid  muscle,   138 

Extroversion   of   bladder,    350, 

459 
Eyeball,  50 

blood  supply  of,  64 

dangerous  area  of,  68 

nerve  supply  of,  66 

Eyelashes,  77 

Eyelids,  75 

arteries  of,  77 

nerves  of,  77 

subcutaneous  tissue  of,  76 

■  sycosis  of,  77 

Face,  116 

>  blood  supply  of,  117 

cellular  tissue  of,  116 

■  development  of,  119 

•  injuries  to,  117 

■  lymphatics  of,  198 

■  nerves  of,  119 

— ■  skin  of,  116 

vessels  of,  117 

Facial  artery,  118,  167 


Facial  nerve,  90,  130 

palsy,  80 

Fallopian  tube,  490 
Fallopius,  aqueduct  of,  90 
Fascia,  abdominal,  336 
.  anal,  452 

axillary,  243,  244 

.  bicipital.  272,  277 

■  brachial,  266 

■.  cervical,  171 

•  clavi-pectoral.  244 

gluteal,  505 

- — -  iliac,  366 

■  lata,  506,  513,  541 

lumborum,  369 

•  obturator,  452 

of  ankle,  591 

■  of  arm,  266 

■  of  buttocks,  505 

,  of  Oolles,  459 

- — -  of  deltoid  region,  250 
_  of  foot,   591 

of  hand,  309 

of  leg,  578 

•  of  scalp,  1.  6 

■  of  Scarpa's  triangle,  513 

■  of  thigh,  541 

palmar,  309 

-  parotid.  127 

•  pectoral,  244 

pelvic,  451 

■  perineal,  459 

■  plantar,  589 

popliteal,  554 

■  postnephric,  431 

■  prenephric,  431 

>  Scarpa's,  362 

■  Sibson's,  175 

■  temporal,  8 

■  transversalis,  366 

■  visceral,  452 

Fasciculated  bladder,  470 
"  Fatty  hernia,"  339 

■  tissue  in  scalp,  2 

Femoral  artery,  507 

diverticula,  366 

epiphysis,  573 

■  hernia,  360 

point,  352 

vessels.  512,  515,  543 

aneurysm  of,  515 

■ phlebitis  of,  515 

Femoro-sacral  arch,  445 
Femur,    dislocations    of, 

570 

epiphysis  of,  525,  530 

■  fractures  of,  527,  544, 

. symptoms  of,  529 

•  lower  end  of,  571 


531, 


571 


660 


SURGICAL   APPLIED   ANATOMY 


Femur,  neck  of,  527 

upper  end  of,   527 

Fenestra  ovalis.  89 

rotunda,  89 

Fergusson's   method   of   divid- 
ing muscles  of  palate,  157 

Fibrous  polyp  of  nose,  108 

sheaths  of  hand,  311 

Fibula.  582 

and    tibia,    fractures    of, 

582,  599 

fractures  of,  584,  599 

Fifth  nerve,  15,  58,  86,  99,  119, 

123 

■  paralysis  of,  58 

Filaria  sanguinis  hominis,  518 
Finger,      little,      "  congenital 
contraction  "  of,  312 

"  snap,"  312 

•  "  mallet,"  318 

Fingers,  avulsion  of,  323 

nerve  supply  of,  325 

Fissure  of  Rolando,  41 

of  Sylvius,  41 

parieto-occipital,  44 

Fissures  of  brain,  39,  42 

of  Santorini,  84 

■  parietal,  21 

Fistula  at  navel,  340 

between  gall-bladder  and 

intestine,  423 

branchial,  200 

congenital,  82,  200 

gastric,  384 

■  in  ano,  458 

-  lachrymal.  81 

recto-vaginal,  489 

salivary,  133 

umbilical,  340 

vesico-vaginal,  489 

Flat-foot,  591,  610 

Flexor   longus    digitorum   ten- 
don, 589 
Fontana,  spaces  of,  72 
Fontanelle,  sagittal,  21 

temporary  occipital,  20 

Fontanelles,  17 

Foot,  587,  603 

abscess  of,  592 

amputations  of,  617 

arches  of,  603 

blood-vessels  of,  589,  596 

bony  points  of,  587 

bursae  about,  594 

club,  608 

dislocations  of,  606,  607 

fascia  of,  591 

flat-,  591,  610 

— —  fractures  of,  613 


Foot,  imprints  of,  612,  613 

integuments  of,  590 

joints  of.  605 

lymphatics  of,  697 

movements  of,  605 

muscles  of,  605 

-  nerves  of,  590 

- — -  perforating  ulcer  of,  591 
•  surface  anatomy  of,  587 

-  synovial  cavities  of,  617 
Foramen  caecum,   152 

infra-orbital,  120 

of  Key,  37 

of  Magendie,  36 

of  Monro,  36 

of  Retzius,  37 

of  Winslow,  376 

ovale,    surface    markings 

of.   123 

■  supra-orbital,  120 

Forearm,  291 

amputation  of,  297 

bones  of,  293 

fractures  of,  295 

luxations  of,  282 

surface  anatomy  of,  291 

vessels  of,  292 

Foreign  bodies  in  air-passages, 

187 
in  bladder,  472 

in  bronchi,  218 

— —  in  caecum,  400 

in  oesophagus,  192 

in  orbit,  54 

in  pharynx,  158 

in  rectum,  493 

in  stomach.  385 

in  trachea,  218 

in   vitreous  humour, 

73 
Fossa    duodeno-jejunalis,    394, 
395 

-  ileo-caecal,  403 

intersigmoid,  407 

ischio-rectal,  457 

nasal,  103,  104 

■  of  Rosenmuller.  95 

•  retrocaecal,  403 

subclavicular,  226 

Fourth  nerve,  paralysis  of,  57 
"  Fracture  helicoide,"  583 
Fractures     (see     the     several 

bones) 
Fraenum  linguae,  147 
Frontal  sinus.   110 

infundibulum  of,  105, 

112 
Funicular  process,  357 
hernia  into,  358 


INDEX 


661 


Galen,  veins  of,  37 
Gall-bladder,  415,  419 

arteries  of,  419 

excision  of,  423 

~  fundus  of,  415 

incision  into,  422 

nerve  supply  of,  420 

operations  on,  422 

relations  of,   415 

rupture  of,   421 

tumour  in.  422 

veins  of.  419 

Gall-stones,  419,  421 
Gangrene  of  leg,  579 

of  small  intestine,  442 

Gasserian    ganglion,    excision 
of,  125 

position  of,  12 

Gastrectomy,  388 
Gastric  fistula,  384 

ulcers,  384 

Gastrocnemius  muscle,  577 

rupture  of,  579 

Gastro-hepatic  omentum,  420 
Gastrojejunostomy,  389 
Gastroplication,  389 
Gastrostomy.  386 
Gastrotomy,  386 
Generative  organs,  female,  488 

. ■  male,  480 

Genito-crural  nerve,  437 
Genu  valgum,  565 

■ ■  epiphysis  in,   567 

Giantism,  39 

Gimbernat's  ligament,  362 
Gladiolus,  205 
Glans  penis,  481 

. . ■  mucous       membrane 

of,  481 
Glaucoma,  61,  62.  74 
Glaucomatous  cup,  75 
Glenard's  disease,  378 
Globe,  59  (see  also  Eyeball) 
Gluteal  abscess,  505 

aneurysms,  507 

artery,  504,   507 

. ■  bursae,  506 

■ ■  fascia.  506 

■ •  fold,  503 

muscle,  506 

■  region,  502 

Gluteus  maximus,  450.  506 

rupture  of,  506 

Goitre,  188 

Granular  lids,  79 
Green-stick  fracture.  233 
Groin,  region  of,  511 
Gubernaculum,    relations    of, 
356 


Gullet  (see  (Esophagus) 
Gummatous       periostitis       of 

sternum,  206 
Gums,  146 

lymphatics  of,  198 

Gustatory  nerve,  146 

Haematoniata  of  scalp,  7 

on  pinna,  85 

Haematuria,  430,  631 
Haemoptysis,  216 
Haemorrhage  from  choroid,  62 

from  lung,  216 

from  tongue,  148 

■  from  tonsil,  164 

from  uterus,  489 

from  vagina,  489 

into  vitreous,  66 

meningeal,  32 

Haemorrhoidal      vessels      and 

nerves,  459,  463,  495 
Haemothorax,  216 
Hallux  rigidus,  616 

■  valgus,  616 

Ham  (see  Popliteal) 
Hammer  toe,  616 
Hamstring  muscles,  550,  554 
Hand,  300 
abscess  of,  311 

amputations  of,  323 

-  blood-vessels  of,  315 

bones  of,  316 

creases  of  skin  of,  303 

■  dislocations  of,  322 

fasciae  of,  309 

fibrous  sheaths  of,  311 

■  joints  of,  316 

lymphatics  of,  315 

- —  nails  of,  308 

nerve  supply  of,  307 

skin  of,  303,  306 

subcutaneous     tissue    of, 

307 
surface  anatomy  of,  302 

synovial  cavities  of,  322 

sacs  of.  312 

■  sheaths  of,   312 

Hanging,  mode  of  death  from, 

645 
Hard  palate,  155 

■  blood  supply  of,  156 

Hare-lip,  153 

Heart,  218 

exposure  of,  220 

relations  of,  219 

wounds  of,  220 

Heel,  blood  supply  of.  617 

integuments  of,  617 

■  nerve  supply  of,  618 


662 


SURGICAL   APPLIED    ANATOMY 


Helicoidal     fractures     of     Le- 

riche,  545,  583 
Hepatic  abscess,  418 
Hernia,   351 

csecal,  399 

congenital,   339,   351,  358 

diaphragmatic,  365 

direct,  354,  355 

encysted,  358 

■  fatty,  339 

femoral,  360 

■ •  indirect,  355 

infantile,  358 

inguinal,  351 

■  internal,  354 

■ into  crural  canal,  362 

into     funicular     process, 

358 

■  ischio-rectal,  364 

-—  lumbar,   364 

■ .  mesenteric,  396 

■  mesocolic,  396 

.  mesogastric,   396 

oblique,   354,   355 

obturator,  363 

.  of  lung,  216 

• omental,  372 

perineal,  364 

■  pudendal,   364,   488 

rare  forms  of,  364 

-  retroperitoneal.  396 
sciatic,  364 

strangulated,  407 

• •  umbilical,  339,  364 

Herniae,  bladder  in,  467 
Hernial  sacs,  351 
Herniotomy,  360,  363 
Herpes  zoster,  348 
Hesselbach's  triangle,  354 
Hiatus  semilunaris,  105 
Highmore,  antrum  of,  113 
Hilum  of  kidney,  428,  436 
Hip,  dislocations  of,  531, 

■ ;  - — —  anatomy  of,   535 

..__  modes    of     reducing, 

538 

region  of,  502 

Hip-joint,  518 

• abscess  in,  518 

amputation  at,  538 

■ .  disease,  520,  525 

■ .  ■  chronic,   521 

•  fractures  about,   527 

movements  of,  520 

nerve  supply  of,  525 

relations  of,   519 

Holden's  line.  511 

"  Hottentot  Venus,"  505 
Human  tails,   450 


Humerus,  225 

•  dislocations    of,    255,    257, 

258    259 

fractures  of,  260,  268,  285 

■  — —  non-union  after,  269 

Hunter's  canal,  543 
Hyaloid  membrane,  73 
Hydatid  cysts  of  lung,  217 
Hydrencephalocele,  19 
Hydrocele,   484 

encysted,  of  cord,  357 

of  neck,  202 

Hydrocephalus,  17,  18,  37 
Hydronephrosis,  433 
Hyo-glossus  muscle,  167 
Hyoid  bone,  166,  179 

. accessory  glands 

about,  189 

— r bursse  about,  179 

■  fracture  of,  179 

■  ■  wounds  of,   177 

Hypertrophy  of  prostate,  475 

of  pylorus,  387 

of  tonsil,  161 

Hypodermic  injection,  510 
Hypogastric  line.  379 
Hypoglossal  nerve,  130,  150 
Hypopyon,  73 
Hypospadias,  482 
Hypothenar  eminence,  302 
Hysterical  hip,   526 
.  knee,  526 

Tleo-csecal  fossa,  403 

intussusception,  402 

■  orifice,  402,  403 

region,   398 

-  sphincter,  400 
• — -  valve,  403 
Ileo-colic  angle,  402 

intussusception,  402 

Ileum  (see  Intestine,  small) 
Iliac  abscess,  342,  367 

■ ■  colon,  405 

■ ■  multiple    diverticula  , 

of  mucous  coat  of,  I- 

409 

■  colotomy,  411 

- — -  fascia,  366 
Ilio-psoas  muscle,  514 
Ilio-tibial  band,  550 
Indirect  hernia,  355 
Infantile  hernia,  358 
Inferior  cava]  point,  218 
dental  nerve,  122 

maxilla,    135 

deformities  of,   140 

dislocations  of,  137 

excision  of,  139 


INDEX 


Inferior  maxilla,  fracture  of, 
135 

nerves  of,  140 

subluxation  of,  138 

mesenteric  artery,  335 

plexus,  440 

— — ■  temporal  convolution,  44 

thyroid  artery,  191 

■  vena  cava,  220 

Infra-orbital  artery,  121 

foramen,  120 

.  nerve,  120 

Infundibulo-pelvic      ligament, 

491 
Infundibulum,  112 

■  of  frontal  sinus,  105.  112 

Inguinal  canal,  359 

colotomy,   411 

■ diverticula.  366 

glands,  512,  516 

■  hernia,  351 

Innominate  artery,  195 

bone,  448 

Intercarpal  joint,  317 
Intercostal  abscess,  209 
artery,  208,  209 

• muscles,  209,  629 

spaces,  208 

Intercosto-humeral  nerve,  213 
Internal  cutaneous  nerve,  277 
hernia,  354 

.  mammary  artery,  210 

Interparietal  bone.  21 
Interscapulo-thoracic  amputa- 
tion, 242 
Intersigmoid  fossa,  407 
Interstitial  keratitis,  60 
Intervertebral  discs,  628 
Intestinal     anastomosis.     397, 

412 
Intestine,  large,   404  (see  also 
Colon) 

■  excision  of,  412 

small,  389 

diverticula  of,  392 

■  gangrene  of,  442 

in  pelvis,  390 

.  injury  to,  391 

length  of,  389 

—  operations  on,  397 

■ ■  •  position  of,  390 

■ •  resection  of,  397 

■  strangulation  of,  340,  393 

Intracranial  abscess,  10 
Intrathoracic     disease,     Ront- 

gen  rays  in,   221 
Intussusception,  402 
Inversion,  movements  of,  605 
Iridectomy,  64,  74 


Iris,  58,  63 

Iritis,  63 

Ischial     spine     as     guide     to 

ureter,  440 
Ischio-rectal  abscess.  458 

.  fossa,  457 

hernia,  364 

Ischio-sacral  arch,  445 
Islets  of  Langerhans,  427 
Isthmus  of  thyroid,  186,  189 

Jaws       (see       Inferior       and 

Superior  maxilla) 
Jejunum,  389 
Joints,    surgical    classification 

of,  251 
Jugular  vein,  90,  91,  168,  198 

Keloid  (see  Cheloid) 
Keratitis,   interstitial,   60 
Key,  foramen  of.  37 
Kidney,  427 

abnormalities  of,  433 

■  abscess  of,  430,  431 

■  development  of,  434 

fusion  of,  434 

hilum  of,  428.  436 

horse-shoe,  434 

movable,  431 

nerve  supply  of,  432,  501 

■  operations  on,  434 

■  pelvis  of,  428.  436 

position  of,  428 

•  relations  of,  427 

rupture  of,  430 

-  "  sacral,"   434 

■  support  of,  432 

■  vessels  of,  335 

Knee,  548 

■  blood  sunply  of,  552 

— -  bursse  about,  553.  557 

-  dislocations  of,  570 
fractures  about,  571 

front  of,  551 

•  blood  supply  of,  552 

skin  of,  551 

subcutaneous         fat 

over.  552 

■  lymph  glands  of,  553,  557 

•  pain      in,      in      hip-joint 

disease,  525 

surface  anatomy  of,  548 

■  (see  also  Popliteal) 

Knee-cap  (see  Patella) 
Knee-joint,  558 

■  amputation  through,  575 

■  crucial  ligaments  of,  558 

derangement  of,  563 

disease.  562 


664 


SURGICAL  APPLIED   ANATOMY 


Knee-joint,  excision  of,  573 

lateral  ligaments  of,  558 

— —  synovial     membrane     of, 

560 
Knock-knee,  565 

■  epiphysis  in.  567 

Kraske's  operation,  496 
Kyphosis,  204,  628 

Labia  majora,  488 
Labyrinth  of  ear,  97 

osseous,  97 

Lachrymal  abscess,  80 

■  apparatus,  79 

■  fistula,  81 

gland,  79 

sac,  79 

Lacuna  magna,  urethral,  480 
Lambda,  17 
Lambdoid  suture,  17 
Lamina  cribrosa.  62 
.  fusca,  62 

suprachoroidea,  62 

Laminae  of  spine,  636 
Laminectomy,  637 
Langerhans,  islets  of,  427 
Laryngotomy,  184,  187 
Larynx,  179 

excision  of,  183 

foreign  bodies  in,  187 

■  fracture  of,   180 

lymphatics    of,    183,    198, 

199 

mucous  membrane  of,  182 

Lateral  curvature,  204 

ligaments    of    knee-joint, 

558 

lithotomy,  462 

muscles  of  abdomen,  341 

■ ■  sinus,  10,  33 

■  ventricles,  44 

Leg,   576 

— — •  aching,  581 

■ ■  amputation  of,  585 

fascia  of,  578 

■ ■  fractures  of,  582 

■ gangrene  of,  579 

nerve  supply  of,  621 

•  pain  in,  581 

■ rickets  affecting  bones  of, 

585 

•  skin  of,  577 

■  surface  anatomy  of.  576 

■ ■  varicose  veins  of,  580 

vessels  of,  579 

Lens,  69 

artery  to,   73 

capsule  of.  70,  72 

Levator  ani,  450,  491,  492 


Levator     cost  arum      muscles, 
629 

palati,  156 

■  palpebrae,  76 

Ligamenta  subflava,  637 
Ligamentum  patellae,  548,  559 

pectinatum  iridis,  72 

"  Lighterman's  bottom,"   507 
Linea  alba,  333,  338 
■  semilunaris.  379 

transversa,  333 

Lip,  lower,  lymphatics  of,  198 
Lipomata    in    deltoid    region, 
250 

in  Scarpa's  triangle,  513 

on  buttocks,  505 

rarity  of,  on  face,  117 

Lips,  143 

Lisfranc's  operation,  620 
Litholapaxy.  462 
Lithotomy,  lateral,  462 

in  children,  464 

■  wounds  in,  463 

■  median,  464 

suprapubic,  465 

Littre's  operation,  408 
Liver,  414 

abscess  of,  418 

-  diseases  of,  441 

■  fixation  of,  416 

■  in  pyaemia,  418 

■ ■  nerve  supply  of,  441 

■ ■  operations  on,  418 

parietal  surface  of,  414 

ptosis  of,  416 

• relations  of,  415 

to  transverse    colon, 

417 

rupture  of,  416 

■  visceral  surface  of,  414 

wounds  of,  417 

Lockjaw,  141 
Longitudinal  sinus,  33 
Longus  colli  muscle,  629 
Lordosis  in  hip-joint  disease, 

522 
Lower  limb,  length  of.  545 

.  . ■  lymphatics  of,  517 

.  . .  nerve  supply  of,  621 

Lumbar  abscesses,  367,  370 

fascia,  356 

— —  glands,  517 
— - -  hernia.  364 

■  puncture,   641 

.  region,  369 

.  of  spine,  630 

. . .  injuries  in,   630, 

645 

triangle,  364 


INDEX 


6(55 


Lumbar    vertebrae,    operation 

for  caries  of,  370 
Lung,  213 

apex  of,  in  neck,  175 

cavities,  drainage  of,  217 

- —  haemorrhage  from,  216 
- — ■  hernia  of,  216 

■  hydatid  cysts  of,  217 

.  in  neck.  213 

relations   of,    to   surface, 

214 

■ root  of,  exposure  of,  218 

rupture  of,  216 

— -  wounds  of,  175,  216,  417 
Lupus  erythematosus,  98 
Luschka's  tonsil,  95 
Lymphangioma      cavernosum, 

151 
Lymphatic  glands  and  vessels 

(see  various  regions) 

Microglossia,  151 
Magendie,  foramen  of,  36 
Malar  bone,  127 

fracture  of,  127 

Malleoli,  587 

fractures   of,    in    disloca- 

tion of  foot,  599 
"  Mallet  finger,"  318 
Mamma,  210 

■  arteries  of,  213 

■  cancer  of,  211 

- — -  capsule  of,  211 
■  development  of,  211 

in  Scarpa's  triangle,  513 

influence  of  ovary  on,  491 

lymphatics  of,  211 

nerves  of,  211 

supernumerary,  213 

Mammary     artery,     internal, 

210 
Manubrium,  205 
Mastication,  muscles  of.  141 
Mastoid  antrum,  91 

cells,  93 

abscess  of,  91 

« perforation  of,  93 

lymphatic  glands,  198 

■  process,  93 

Maxillae    (see    under    Inferior 

and  Superior) 
Meatus,  auditory.  83 

■  of  urethra,  479 

Meatuses  of  nose,  105 
Meckel's  diverticulum,  340,  392 
■  ganglion,  120 

space.  126 

Median  artery.  316 
— -  basilic  vein,  276 


Median  cephalic  vein.  276 

■  commissure    of    prostate, 

473 
■ ■  lithotomy,  464 

nerve,  293 

paralysis  of,  329 

Mediastina,  221 

— —  abscess  of,  221 

glands  of,  198 

Mediotarsal  joint,  608 

amputation  at,  619 

Medulla  spinalis    638 
Meibomian  glands,  77 
Membrana  tympani,  87 

. ■  umbo  of,  88 

Meningeal  artery,  9,  32 

.  haemorrhage,     trephining 

for,  9 
Meninges  of  brain,  31 

■  of  spinal  cord,  638,  639 

Meningitis     from     abscess     in 

ear,  84,  90 
from      inflammation      of 

nasal  fossae,  104 
■  spinal,   from    bed  -  sores, 

640 
Meningocele,  19,  100.  104 

spinal,  651 

Meningo-myelocele,  651 
Mercier's  bar,  471 
Mesenteric  arteries,  335,  442 
hernia,  396 

■  plexus,  440 

Mesentery,  373 

holes  in,  375 

■  imperfect  attachments  of, 

375 

length  of.  358,  374 

■  of  appendix,  401 

prolapse  of,  374 

Meso-appendix.  401 
Mesocolic  hernia,  396 
Mesocolon,  405 
Mesogastric  hernia,  396 
Metacarpo-phalangeal  joint  of 

thumb,  dislocations  at,  322 
Metatarsal  bones,  fractures  of, 

614 
Metatarso  -  phalangeal     joint, 

588 
Micturition  in  spinal  injuries, 

649 
Mid-carpal  joint,  317 
Middle  meningeal  artery,  9,  32 

.  trephining  for,  9 

Mid-epigastric  point,  334,  379 
Mid-hypogastric  point,  379 
"  Miner's  elbow,"  279 
Monro,  foramen  of,  36 


66G 


SURGICAL   APPLIED    ANATOMY 


Monro's  point,  380 

Morgagni,  columns  of,  497 

Motor  centres,  40 

■  paralysis    in    injuries    to 

cord,  648 

Mouth,  143 

• cysts  in  floor  of,  146 

•  dermoid  cysts  of,  146 

■  roof  of,  lymphatics  of,  199 

■  thyroid  cysts  of,  146 

Movable  kidney,  431 

Mucous  membrane  of  anal 
canal,  497,  498 

■  ■  of  bladder,  469 

of  duodenum,  diver- 
ticula of,  395 

of  glans  penis,  481 

of  larynx,  182 

■  ■  of  nose,  107 

of  pharynx,  95,  159 

■  ■  of  rectum,  494 

■ of  urethra,  480 

polyp  of  nose,  107 

Miiller's  muscle,  59 
Multifidus  spinas  muscles,  629 
Muscles,  functional   classifica- 
tion of,  317 
Musculo-cutaneous  nerve,  331 
Musculo-spiral  nerve.  268 

■  ■  paralysis  of,   329 

Myxcedema,  190 

Myxomatous  polyp  of  nose,  107 

Nails  of  hand,  308 
Nares.  anterior,  100 

posterior,  101 

Nasal  bones,  99 

•  fracture  of,  99 

■  cavities,  100 

blood  supply  of,  108 

lymphatics  of,  110 

■  nerves  of,  109 

of  children,  102 

-  douche,  103 

duct,  81,  105 

fossa*.  103,  104 

lymphatics  of,  199 

•  polypi,   107 

■ ■  septum,   104 

sinuses,  110 

(see  also  Nose) 

Naso-pharyngeal  tonsil,  159 
Navel,  335,  339 

■  fistula  at,   340 

Neck,   165 

■  abscess  of,  174 

■  air-sac  in,  202 

apex  of  lung  in,  213 

•  blood-vessels  of,  194 


Neck,  bony  points  of,  165 

■  fasciae  of,  171 

■  fistulas  of,  200 

■  hydrocele  of,  202 

lung  in,  175,  213 

lymphatic  glands  of,  196 

198 

middle  line  of,  166 

■  muscles  of,  166 

■  nerves  of.  169 

■  ribs  in,  175 

•  side  of,  166 

■  skin  of,  170 

surface  anatomy  of,  165 

vessels  of,  167,  178 

wounds  of,  177 

Necrosis  of  cranial  bones,  5 
■  of  skull.  21 

•  of  superior  maxilla.  134 

Nelaton's  line,  503 
Nephrectomy,  434 
Nephro-lithotomy,  434 
Nephrorrhaphy,  434 
Nephrotomy,  434 
Nerve-injecting,  509 
Nerve-stretching,  509 
Nerves  (see  various  regions) 

division    of    (see    various 

trunks) 
Neural  arches,  650 
Neuralgia,  facial,  120 
Neuritis,  optic,  71 

retrobulbar,  71 

Nipple.  211 

Nipples,  supernumerary,  213 

Nose,  98 

■  bleeding  from,  108 

cartilaginous  part  of,  99 

■  mucous  membrane  of,  107 

skin  of,  98 

•  (see  also  Nasal) 

Notch  of  Rivini,  88 
Nuck,  canal  of,  359 

Oblique,  internal  and  external, 

muscles,  629 
Obturator    artery,    abnormal, 
362 

canal,   3"63 

■  dislocation,   533,    536 

fascia,  452 

hernia,  363 

nerve,   526,   624 

Occipital  artery,   168 
— —  bone  at  birth,  19 

necrosis  of,  149 

•  fontanelle,  temporary,  20 

lymphatic  glands,  198 

Occlusion  of  duodenum,  395 


INDEX 


667 


Oculomotor   nerves,  paralysis 

of,  58 
Odontoid  process.  636 
(Esophagotomy,  194 
(Esophagus,  191 

cancer  of,  193 

■  foreign  bodies  in,  192 

; — -»  malformations  of,  193 

nerve  supply  of,  193 

. ■  relations  of,  192 

Olecranon,  274 

epiphysis  of,  288 

. ■  fractures  of,   288 

Omega  loop  of  colon,  407 
Omental  hernia,  373 

■  sac,  373 

Omentum,  great,  372 
Omo-hyoid.  167 
Onychia,  308 
Ophthalmia,  purulent,  79 

.  sympathetic,  69 

Optic  disc,  71 

foramen,  71 

nerve,  71 

■  neuritis,  71 

■  thalamus,  44 

Ora  serrata,  71 

Orbicularis  palpebrarum,  76 

Orbit,  50 

■  abscess  of,  54 

■  arteries  of,  56 

■  fasciae  of,  52 

■  foreign  bodies  in,  54 

■  fracture  of,  50 

lymphatics  of,  199 

■  muscles  of,  55 

■  nerves  of,  56 

.  ■  paralysis  of,  57 

■  pulsating  tumours  of,  56 

relations  of.  51 

Orbital  walls,  relations  of,  51 
Os  calcis,  587 

dislocations  of,  606 

.  fractures  of,  613 

epactal,  21 

innominatum,  448 

■  magnum,    dislocation    of, 

322 
Osseous  labyrinth.  97 
Ossicles  of  ear,  88 
Ovario-pelvic  ligament,  491 
Ovary,  490 

■  influence  of,  491 

■ lymphatics  of,  490 

nerves  of,  490 

Pacinian  bodies  in  foot,  590 

in  hand,  307 

Palate,  153 


Palate,  cleft,  153 

development  of,  153 

hard,  155 

lymphatics  of,  199 

■  soft,  156 

Palmar  {see  Hand) 
Palmaris   longus   tendon,   300 
Pampiniform  plexus,  487 
Pancreas,  425 

relations  of.  415,  425 

Pancreatic  ducts,  425,  426 
Pannus,  61 
Paracentesis,  208 

of  pericardium,  221 

of  thorax,  209 

Paralysis    in    spinal    injuries, 
'648 

-  of  anterior  crural  nerve, 

621 

of  brachial  plexus,  324 

of    cervical    sympathetic, 

58 

of  Erb,  249  '  ;  ■ 

.  of       external       popliteal 

nerve,  624 

of  facial  nerve,  131 

of  first    division    of    fifth 

nerve,  58 

of  fourth  nerve,  57 

• of  great  sciatic  nerve,  625 

of       internal       popliteal 

nerve,  624 

of  median  nerve.  329 

of  musculo-spiral     nerve, 

268.  329 

of  obturator  nerve,  624 

of  oculo-motor  nerves,  58 

of  orbital  nerves,  57 

-  of  sixth  nerve,  57 
of  third  nerve.  57 

of  ulnar  nerve,  331 

Parasinoids.  33 
Parathyroid  bodies,  190 
Parietal  bone,  relations  of,  21, 

43 

fissures,  21 

Parieto-occipital  fissure,  44 
Paronychia,  308 
Parotid  abscess,  129 
■  fascia,  127 

gland,  127,  132,  196 

.  nerve  supply,   129 

region,  127 

— —  •  structures,  131 
—  -  tumours,   132 
Patella,  548,  560 

■  blood  supply  of,  569 

■  congenital  absence  of,  569 

■  development  of,  569 


668 


SUKGICAL   APPLIED    ANATOMY 


Patella,  dislocation  of,  569 

fractures  of,  567 

Patellar  bursa,  553 

•  ligament,  548,  561 

Pectoral  glands,  212 
Pectoralis  major,  227 
— —  minor,  228 
Pelvic  abscess,  518 

arch,  445 

-  colon,  407 

multiple    diverticula 

of  mucous  coat  of, 
409 

fascia,  451 

symphysis,  448 

viscera,  453 

fixation  of,  453 

■  movements  of,  453 

Pelvis,  438,  445 

floor  of,  451 

fractures  of,  447 

mechanism  of,  445 

— —  nerves  of,  499 

renal,  428,  436 

rickety,  446 

small  intestine  in,  390 

subserous  tissue  of,  454 

Penile  urethra,  477,  479 
Penis,  480 

lymphatics  of,  481 

■  skin  of,  480 

nerves  of,  500 

vascularity  of,  481 

Perforating  ulcer  of  foot.  591 
Pericardium,  218 

paracentesis  of,  221 

Pericranium,  5 
Perineal  fascia.  459 

hernia,  364 

Perinephritic  abscess,  430 
Perineum,  455 

— -  depth  of,  457 
— —  male,  455 
— —  nerves  of,  499 

vessels  of,  456 

Periosteum,  5 
Perirenal  capsule,  431 

• opening  of,  436 

Peritoneal       communications, 

375 

spaces,   375 

Peritoneum.  342.  371 
fossae  of,  354,  403 

relations   of    bladder    to, 

465,  466,  467 

watersheds  of.  376 

Peroneal  artery.  577,  579 
muscles,  577 

— —  nerve,  555 


Peroneal  tendon,  589 

-  tubercle,  588 
Peroneus  tendon,  589 
Petit's  triangle,  334 
Petro-squamous  suture,  90 

vein,  90 

Phalanges,  fractures  of,  614 
Phalanx  of  great  toe,  disloca- 
tion of.  615 

Phantom  tumour,  340 
Pharyngeal  orifice,  95 

pouches,  193 

•  recess,  95 

tonsil,  95 

Pharynx,  158 

dimensions  of,  158 

excision  of,  161 

foreign  bodies  in,  158 

lymphatics  of,  199 

mucous  membrane  of,  95, 

159 
•  nerves  of,  161 

-  relations  of,  159 
Phlebitis  of  femoral,  515 
Photophobia,  67,  68 
Phrenic  nerve,  169,  217 
Pigeon  breast,  203 
Piles,  495 

Pinna,  82  (see  also  Ear) 
Pirogoff's  amputation,  618 
Pituitary  body,  37 
Plantar  (see  Foot) 
Plantaris  muscle,  rupture  of, 
579 

tendon,  rupture  of,  579 

Platysma  myoides,  170 
Pleura,  215 

■ nerve  supply  of,  217 

opening  of,   436 

relations    of,   to    surface, 

214 

wounds  of,  175,  215 

Plica  vascularis,  relations  of, 

356 
Pneumatoceles,  94 
Pneumothorax,  215,  216 
Politzer's  method  of  inflating 

middle  ear,  94 
Pollock's  method   of   dividing 

muscles  of  palate.  157 
Polypi,  nasal,  107 
Popliteal  abscess,  554 
bursse,  557 

fascia,  554 

■  glands,  557 

nerve,  external,  paralysis 

of,  624 

internal,       paralysis 

of,  624 


INDEX 


669 


Popliteal  nerves,  551.  554 

■ ■  space,  550 

skin  of,  553 

vessels,  550.  555,  577 

Portal  vein,  373,  442 
Postauricular         lymphatic 

glands.   198 
Posterior  nares,  101 
Postnasal  growths,  160 
Postnephric  fascia.  431 
Postpharyngeal  abscess,  160 
Potential  spaces,  375 
Pott's  disease.  203,  637 

fracture,  602 

Poup art's  ligament,  333 
Preauricular  lymphatic 

glands,  198 
Prenephric  fascia,  431 
Preputial  ocelli,  482 
Processus  funicularis.  357 

vaginalis,  351,  357 

relations  of,  356 

Pronation,  294 
Prostate,  462,  473 

— —  abscess  of,  475 

capsule  of,  474 

commissures  of,  473 

hypertrophy  of,  475 

lobes  of,  473 

■  lymphatics  of,  476 

muscles  of,  462 

nerves  of,  475 

■  secretion  of.  474 

■  sheath  of,  462,  474 

Prostatectomy,  476 
Prostatic  ducts,  474 

■  urethra,  477.  478 

.  venous  plexus,  462 

Prostatitis,  475 

Protopathic     sensibility,     124, 

330 
Pruritus  ani,  497 
Psoas  abscess,  368,  513 

■ ■  muscle,  437.  513.  629 

Pterion,  42 

Pterygoid     muscle,     external, 

138 
Pterygo-maxillary      ligament, 

146 
Ptosis  of  eyelid.  57 
■ of  liver,  416 

of  stomach,  382 

Pubes,   dislocation    upon,    533. 

537 
Pubic     commissure     of     pros- 
tate, 473 

spine,   333 

Pudendal  hernia,  364,  488 
Pudic  artery,  504 


Pulmonary  apoplexy,  216 
Pupillary  membrane,  64 
Purulent  ophthalmia,  79 
Pyaemia,  liver  in,  418 
Pyloric  orifice,  381 
Pyloroplasty,  389 
Pylorus,  382,  387 
— —  cancer  of,  427 

.  hypertrophy  of,  387 

•  resection  of,  388 

Quadratus  lumborum  muscle, 

629 
Quadriceps  of  thigh.  542 

Radial  artery,  292,  315,  316 

■  nerve,  329 

Radio-carpal  joint,  317 
Radio-humeral  joint,  274 
Radius,  dislocation  of,  282 
fractures  of,  289,  296 

surface  markings  of,  292 

Ranula.  145 

— —  acute,  146 

Rectal    commissure    of    pros- 
tate, 473 
Recti,  divarication  of,  338 
Rectocele,  vaginal.  489 
Recto-vaginal  fistula,  489 

wall,  rupture  of.  498 

Recto-vesical  pouch,  468,  491 
Rectum,  406,  491 

■  attachments  of,  494 

cancer  of,  496 

congenital  absence  of,  408 

deficiency  of,  408 

distension  of,  493 

excision  of,  493 

-  folds  of,  495 

■  foreign  bodies  in.  493 

in  infant,  409 

introduction       of       hand 

into,  493 
lymphatics  of,  496 

-  mucous  membrane  of,  494 
—  nerve  supply  of.  497 

— -  serous  membrane  of,  491 

valves  of,  495 

«  vessels  of.  495 

Rectus  abdominis  muscle,  338, 

340,  629 
Recurrent     laryngeal     nerve, 

191 
Referred    pain,    140,    328,    329, 

348,  441,  581,  598 
Reflex  contraction,  341 
Renal  abscess,  431 

■  artery,  436 

pelvis,  428,  436 


670 


SURGICAL    APPLIED    ANATOMY 


Renal  plexus,  432 

■  tumours,  436 

•  {see  also  Kidney) 

Respiration  in  spinal  injuries, 

648 
Retina,  70 

■  vessels  of,  65,  66 

Retrobulbar  neuritis,  71 
Retrocsecal  fossa,  403 
Retroperitoneal  hernia,  396 
Retropharyngeal  abscess,  368 
Retropubic  space,  467 
Retzius,  foramen  of,  37 
Rhinoplasty,  99 
Rhinoscopy,  101 
Ribs,  206 

>  cervical,  175 

effect  of  rickets  on,  208 

excision  of,  209 

fractures  of,  207 

Rickets,  effect  of,  on  pelvis,  446 
__  on  ribs,  208 

— ■  on  skull,  18 

■  on  tibia,  585 

Rickety  pelvis.  446 
"  — —  rosary,"  208 
Rider's  bone,  515 

sprains,  514 

Riedel's  lobe,  416 
Rima  glottidis,  166,  181 
Rivini,  notch  of,  88 
Rolando,  fisure  of,  41 
Rontgen  rays  in  intrathoracic 

disease,  221 
Rosenmuller.  fossa  of,  95 
Rouge's  operation,  101 

Sacculated  bladder,  470 
Sacro-coccygeal  joint,  450 

tumours,  450 

Sacro-iliac  synchondrosis,  445, 

449 
nerve     relations     of, 

449 
Sacro-sciatic  notch,  440 
Sacrum,  445 

dislocation  of,  449 

Sagittal  fontanelle,  21 

suture,  17 

Salivary  fistulae,  133 
Santorini,  duct  of,  425 

fissures  of,  84 

Saphenous  nerve,  551,  577 
opening,  361,  512 

veins,    512,    516,    551,    557, 

577 
Sarcomatous    polyp    of    nose, 

108 
Sartorius  muscle,  511,  514 


Scalene  muscles,  167 
Scalp,  abscess  of,  6 

blood  tumours  of,  7 

■  blood-vessels  of,  13 

connective  tissue  of,  3 

cysts  of,  2 

- —  dangerous  area  of,  3 

erysipelas  of,  14 

fascia  of,  1,  6 

fatty  tissue  in,  2 

haematomata  of,  7 

•  lymphatics  of,  16,  198 

-  mobility  of.  3,  4 

nerves  of,   13,  16 

■  sebaceous  tumours  of,  2 

— — -  skin  of,  1 

subcutaneous  tissue  of,  1 

suppuration  in,  6 

— —  vascularity  of,  4 

wounds  of,  3 

bleeding  from,  4 

Scaphoid,  dislocation  of,  605 

-  fracture  of,  321 
Scapula,  224,  225,  239 
— -  excision  of,  242 
fracture  of.  240 

■  of  body  of.  241 

through  surgical 

neck  of,  241 

movements  of,  239 

•  tumours  of.  242 

.  "  winging  "   of.    240 

Scarpa's  fascia,   362 

triangle,  511 

blood-vessels  of,  515 

bursa  about,  514 

fascia  of,  513 

lymphatic  glands  of, 

512,  516 

mamma  in,  513 

muscles  of,  514 

nerves  of,  516 

■ —  skin  of,  512 

surface   anatomy   of, 

511 

— — ■ •  testicle  in,  513 

Schlemm,  canal  of,  79.  73 
Sciatic  artery.  504,  507 
■  hernia,  364 

nerve,  great,  504,  508 

paralysis  of,  625 

relations  of,  508 

-  notch,     dislocation     into, 

533 
Sciatica,  509 
Sclerotic,  61 
Scoliosis,  204,  629 
Scrotum,  482 

and  oedema,  483 


INDEX 


671 


Scrotum,        application        of 
leeches  to,  483 

lymphatics  of,  485 

— — ■  rugae  on  surface  of,  483 

skin  of.  482 
nerves  of,  500 

subcutaneous     tissue     of, 

483 
Sebaceous  tumours  of  scalp.  2 
Semilunar  cartilages,   disloca- 
tion of,  563 

• >  fixation  of,  564 

■  ■  movements  of.  564 

Semimembranosus  tendon,  550 
Semispinalis  muscle,  629 
Semitendinosus  tendon,  550 
Sensori-motor  areas  of  brain, 

40,  45 
Sensory  nerve,  123 

-  paralysis    in    injuries    to 

cord,  648 
Septum  of  nose,  104 
Sesamoid  bones,  615 
Short-circuiting.  397,  412 
Shoulder,  224 

■  surface  anatomy  of,  224 

Shoulder-joint.  251 

■  amputation  at,  262 

bursse  about,  252 

■  capsule  of.  252 

disease  of,  253 

■  dislocation     of,    255,     257, 

258,  259 
—  common  features  of, 

256 
■  special    anatomy    of 

all  forms  of,  257 

fractures  about,  260 

■  relations  of,  243 

Sibson's  fascia,  175 
Sigaultean  operation,  448 
Sigmoid  flexure,  406 

-  hernia,  407 
— -  mesocolon,  407 

Sinus,  accessory,  110 

cavernous,  33 

frontal.  110 

lateral,  33 

■  pocularis,  477 

■  sphenoidal.  113 

superior  longitudinal,  33 

Sinuses,  nasal.  110 

•  venous,  32 

Sixth  nerve,  paralysis  of,  57 
Skull,  17 

■  abnormalities  of,  19 

■  at  birth,  20,  30 

cap,  thickness  of,  30 

deformities  of,  19 


Skull,  development  of,  18 

effect  of  rickets  on,  18 

emissary  veins  of,  13 

.  fractures  of,  22.  26,  27 

necrosis  of,  5.  2 J 

of  infant,  17.  23,  30 

pillars  of,  24 

soft  parts  covering,  1 

■  sutures  of,  17,  19,  29 

closure  of,  24 

•  separation  of,  29 

■  thickness  of,  30 

■  trephining,   9 

■  venous  tumours  of,  15 

Smith's    (Stephen)    operation, 

575 
Soft  palate,  155 

blood  supply  of,  157 

■  ■  muscles  of.  157 

-  nerves  of,  158 

Solar  plexus,  440 
Soleus  muscle,  577,  579 
Spermatic  artery,  487 

cord,  486 

— — ■  •  arteries  of,  487 

■  plexus  of  veins,  487 

Sphenoidal  sinus,  113 
Sphincter  ani,  450,  493 
Spina  bifida,  650 
Spinal  accessory  nerve,  169 

-  analgesia,  642 
—  cord,  638 

■  — —  blood  supply  of,  643 

■  concussion  of,  643 

— —  contusion  and  crush- 
ing of,  645 

loss  of  motion  due  to 

injury  of.  648 
of  sensation  due 

to    injury    of. 

648 

■  ■  operations  on,  651 

■  protection  of.  633 

■  —  wounds   of,    179,    642, 

643 

•  dura  mater,  639 

■  injuries    and    defsecation, 

649 

and  micturition,  649 

■ and  respiration,  643 

■  and  vomiting,  650 

membranes,    sections    of, 

642,  643 

■  meninges,  638,  639 

•  meningitis.  639.  640 

meningocele,  651 

■  muscles,  629 

■  nerves,     distribution     of, 

625,  646 


672 


SURGICAL  APPLIED  ANATOMY 


Spinal  nerves,  points  of  exit 
of,  from  verte- 
bral canal,  647 

. ,  . , 0f  origin  of,  647 

Spine,  627 

anterior  superior,  333 

■  caries  of,  637 

curvature  of,  204,  627 

•  dislocations  of,  632 

fracture-dislocations      of, 

634 
.  fractures  of,  632 

how     maintained     erect, 

629 
-- —  kyphosis  of,  204 

■  mechanism  of,  632 

movements  of,  628 

.  of  infant,  628 

■  pubic,  333 

■  scoliosis  of,  204,  629 

•  sprains  of,  630 

■  trephining,  637 

Spino-umbilical  line,  380 
Spinous  processes,  fracture  of, 

636 
Splay-foot.  610 
Spleen,  423 
capsule  of,  424 

dislocation  of,  423 

enlarged,  424 

extirpation  of,  425 

injuries  to,  424 

relations  of,  423 

■  rupture  of,  424 

Stenson's  duct,  132 
Stercoral  ulcers,  400 
Sterno-clavicular  joint,  234 

— disease  of,  235 

dislocations  of,  236 

. movements  of,  235 

Sterno-ensiform  line,  379 

■  point,  219,  334,  379 

Sterno-manubrial     joint,     205, 

218 
Sterno-mastoid     muscle,      166, 

170 
Ster no-xiphoid  joint,  205 
Sternum,  205 

■  caries  of,  206 

fracture  of,  205 

■ ■  gummatous  periostitis  of, 

206 

■  holes  in,  206 

- — -  trephining,  206 
Stomach,  381 

■  cancer  of,  223,  388 

■  dilatation  of,  382 

diseases  of,  441 

■ ■  displacement  of,  379 


of. 


Stomach,  fistulae  of,  384 

foreign  bodies  in,  385 

functional     divisions 

382 

■  lymphatics  of,  385 

operations  on,  3815,  389 

— —  ptosis  of,  382 

relations  of,  381 

shape  of,  382 

•  wounds  of,  384 

Stovaine,     injection     of,     into 

subarachnoid  space,  642 
Strabismus,  55,  57 
Strangulated  bowel,  340,  393 

•  hernia.  407 

testicle,  484 

Stylo-maxillary  ligament,  172 
Subacromial  bursa,  252 
Subarachnoid  space,  34.  640 

■  injection  of  stovaine 

into,  642 
Subastragaloid     amputations, 
621 

■  dislocations  of  foot,  607 

■  joint,  605 

Subclavian  artery,  168,  195 

■  vein,  169,  229 

Subclavicular  fossa,  226 
Subclavius  muscle,  230 
Subcoracoid      dislocation      of 

humerus,  257 
Subcutaneous    tissue    of    eye- 
lids, 76 

■ of  scalp,  1 

Subdural  space,  34,  640 
Subfascial  abscess,  353 
Subglenoid       dislocation 

humerus,  259 
Sublingual  gland,  144 

■  papillae,  144 

Subluxation  of  jaw.   138 
Submaxillary      Ivmphatic 

glands,  145,  150,  196 
Subperitoneal    connective   tis- 
sue, 342 
Subscapular  glands,  212 
Subserous  tissue  of  pelvis,  454 
Subspinous       dislocation       of 

humerus,  259 
Superficial  cervical  glands,  198 

. nerve,  169 

•  eoigastric  vein,  335 

Superior     longitudinal    sinus, 
33 

•  maxilla,  133 

■  antrum  of.  113 

. cleft  of.  153 

■ excision  of,  134 

— ■ fracture  of,  133 


of 


INDEX 


673 


Superior  maxilla,  necrosis  of, 
134 

■  nerves  of,  140 

•  mesenteric  artery,  335 

. plexus.  440 

thyroid  artery,  167,  191 

vena  cava,  220 

Supernumerary  auricles,  202 

mamma.  213 

.  in        Scarpa's        tri- 
angle, 513 

nipples,  213 

Supination,  294 
Supinator  longus,  275 
Suppuration  in  hip-joint,  520 

in  scalp,  6 

Supra-acromial  nerve,  169 
Supraclavicular     nerves,     169, 

229 
Supracondyloid    process,    268, 

278 
Suprahyoid  lymphatic  glands, 

196 
Supra-orbital  foramen,  120 
Suprapubic  lithotomy,  465 
Suprarenal  artery,  335 

-  bodies,  437 

•  tumours,  437 

Suprascapular  artery,  169 
Suprasternal  nerve.  169 
Suspensory  ligament,  53,  70 
Sustentaculum  tali,  605 

. fracture  of,  614 

Suture,  lambdoid,  17 

■  sagittal,  17 

Sutures  of  skull,  17,  19,  29 

. closure  of,  24 

. separation  of,  29 

Sycosis  of  eyelids,  77 
Sylvius,  fissure  of.  41 
Symblepharon,  78 
Syme's  amputation,  617 
Sympathetic  ophthalmia,  69 

■  pains,  441 

Symphysis  of  pelvis,  448 
Synostosis  of  skull,  24 
Synovial  cavities  of  foot,  617 
.  of  hand,  322 

membrane   of   knee-joint, 

560 

sacs  of  hand,  312 

sheaths  of  ankle.  592,  593 

■ of  hand,  312 

Synovitis,  acute,  in  hip- joint, 
520 

■ in  knee-joint,  562 

Syphilis,  hereditary.  18 
Syringo-myelocele,  651 
Systolic  empty  bladder.  466 


Tabatiere  anatomique,  305 
Tagliacozzi's  operation,  265 
Talipes  calcaneus,  608 

•  cavus.  591 

— —  equinus,  608 

mixed  forms  of,  610 

— — -  valgus,  609 

.  varus,  607,  609 

Talma-Morrison  operation,  443 
Tarsal  bones,  613 

. ■  dislocations  of,  613 

. fractures  of,  613 

ossification  of,  615 

•  plate,  76 

Tarsectomy,  610 
Tarso-metatarsal  joint,  620 
Tarsus  (see  Tarsal  bones) 
Taxis,  360 
Teeth,  141 

alveolar  abscesses  of,  142 

■  caries  of,  140 

■  permanent,  141 

•  temporary,  141 

■  wisdom.  142 

Tegmen  tympani,  11 
Temporal       convolution,       in- 
ferior, 44 
■  fascia,  8 

fossa,  abscesses  in,  8 

•  region,  8 

■ >  trephining  in,  8 

Temporo  -  maxillary  articula- 
tion, 137 

• ■  dislocation  at,  137 

-  ■  ■  movements  of,  137 

Temporo-sphenoidal      abscess, 

10 
Tendo  Achillis.  579,  588 

■  oculi,  79 

Tenon,  capsule  of,  52 
Tenotomy  at  ankle,  588 
Tensor  palati,  156 
Testicle,  355,  484 
■  descent  of,  355,  484 

in  Scarpa's  triangle,  513 

■  inversion  of,  485 

■  lymphatics  of,  485 

nerve  supply  of,  485,  501 

— —  retained,  484 

•  strangulated,  484 

■  torsion  of.  484 

«  tunic  of,  485 

-  vessels  of,  487 
Thecal  abscess.  314 
Thenar  eminence,  302 
Thigh,  540 

amputation  of,  546 

■  ■  at  hip- joint,  538 

■  fascia  of,  541 


674 


SURGICAL   APPLIED   ANATOMY 


Thigh,  femoral  artery  of,  543 

fracture  of,  544 

■  shortening     of    limb 

after,  545 

integuments  of,  541 

■  muscles  of,  539,  542 

rupture  of,  542 

— — -  nerves  of,  539 

-  skin  of,  541 

surface  anatomy  of,  540 

Third  nerve,  paralysis  of.  57 
Thoracic  duct,  199,  223,  443 

wounds  of,  443 

Thoracoplasty,  209 
Thorax,  203 

deformities  of,  204 

paracentesis  of,  208 

viscera  of,  213 

■  walls  of.  203 

— —  wounds  of,  216 
Throat,  cut,  177 
Thumb,  amputation  of,  324 
■  dislocation  of,  322 

-  movements  of,  331 
Thymus,  186 
Thyro-glossal  duct,   189 
Thyro-hyoid  space,  wounds  of, 

177 
Thyroid  artery,  superior,  167 
■  body,  188 

■  accessory   glands   of, 

189 
■  atrophy  of,  190 

development  of,  189 

■ in  tracheotomy,  186 

isthmus  of,  186.  189 

-  ■  lymphatics  of,  190 

■  cartilage,  180 

■  cysts,  congenital,  146 

dislocation,  533,  536 

Thyroidea  ima  artery,  191 
Thyrotomy,  183 
Tibia,  582 

and    fibula,    fractures   of, 

582,  599 
— —  epiphysis  of,  574 
— -  fractures  of,  572,  584.  599 
— —  ossification  of,  573 
— — ■  rickets  affecting,  585 

•  upper  end  of.  572 

Tibial  vessels,  577,  579 
Tibialis  anticus  muscle,  576 

. ■  tendon,  588 

■ posticus  tendon,  589 

Toe,  great,  dislocation  of,  615 

Tongue,  147 

■  accessory  glands  of.  151 

blood  supply  of,  148 

cancer  of.  151 


Tongue,  epithelium  of,  148 
■  excision  of,  152 

lymphatics  of,  150,  198 

nerves  of,  148 

■  removal  of,  153 

Tongue-tie,  147 
Tonsil,  161 

>  blood  supply  of,  164 

— — -  hypertrophy  of,  161 

causing  deafness,  163 

■  lingual,   150 

Luschka's,  95 

lymphatics  of,  161,  199 

malignant  growths  of,  164 

naso-pharyngeal,  159 

■  palatinus.  155 

— —  pharyngeal,  95 
Trachea,  179,  184,  217 

■  foreign  bodies  in,  187,  218 

•  wounds  of,  178 

Tracheotomy,  184.  185  / 

Transpyloric  plane,  379 
Transversalis  fascia,  366 
Transverse  cervical  artery,  169i 

• ■  colon,  405 

process  of  atlas,  165 

of  cervical  vertebrae, 

165 
of  lumbar  vertebra}, 

636 
Trapezium,  302 
Traumatic  aneurysms,  56 
Trendelenburg's  operation,  450 
Trephining.  9,  637 

.. for  cerebral  abscess,  9 

■ •  tumour,  11 

for  meningeal  artery,  9 

■  haemorrhage.  9 

in  temporal  region,  8 

Triangular    ligament    of    ure- 
thra, 460 

Trigone,  469 

Tripodism,  450 

Trismus,  141 

Tuber  ischii,  445,  503 

Tumour,  blood,  of  scalp,  7 

. ■  on  pinna,  85 

cerebral,    trephining    for, 

11 
■  fluid,  of  vertebral   canal, 

650 

.  in  gall-bladder,  422 

■  parotid,  132 

.  phantom,  340 

•  renal,  436 

-  sacro-coccygeal.  450 
■  scapular,  242 

•  suprarenal,  437 

venous,  of  skull,  15 


INDEX 


675 


Turl 


Tunica  abdoininalis,  336 

albuginea,  485 

vaginalis,  357 
Turbinate  body,  107 

■  process,  106 

Tympanites,  392 
Tympanum,  89 

attic  of,  88,  91 

■  blood  supply  of,  96 

>  lymphatics  of,  96 

Typhlitis,  400,  401 

Ulcer,  perforating,  of  foot,  591 
Ulna,  dislocation  of.  282 

■  fracture  of,  297 

Ulnar  artery,  315 

nerve,  278 

• ■  ■  paralysis  of,  331 

■ ■  section  of,  330 

vein,  276 

Jmbilical  fistula,  340 

hernia,  339,  364 

—  line,  379 
Jmbilicus.  333 

■  fibrous  ring  of,  339 

vessels  of,  339 

Umbo  of  membrana  tympani, 

88 
Upper  limb,  epiphyses  of,  331 

nerve  supply  of,  324 

Urachus,  340,  353 
Ureter,  437,  471 

distension  of,  438,  471 

■  kinking  of,  433 

■  radiographic        examina- 
tion of,  438 

relations  of,  437 

resection  of.  440 

■  rupture  of,  438 

Urethra,  female,  480 
■  male,  476 

■  catheterism  of,  477 

•  curve  of,  476 

■ ■  narrowest    parts    of, 

479 

■ •  rupture  of,  480 

■  spasmodic     stricture 

of,  479 

■  membranous,  460.  479 

•  mucous  membrane  of,  480 

nerve  supply  of, 

500 

•  penile,  477,  479 

•  prostatic,   477,  478; 

Urethral  canal.  478 

•  triangle,  455,  459 

Uterus,  489 

artery  of,  490 

-  cervix  of,  490 


Uterus,  lymphatics  of,  490 
■  wounds  of,  490 

Vagina,  489 

wounds  of,  489 

Vaginal  cystocele,  489 

■  enterocele,  489 

■  process,  355 

— _  of  peritoneum.  351 

■  rectocele,  489 

Valsalva's  method  of  inflating 

middle  ear,  94 
Valves  in  veins,  196 
Varicocele,  488 
Varicose  veins,  487,  515,  580 
Vas  aberrans,  268 

•  deferens,  486 

■ rupture  of,  486 

Vater,  ampulla  of,  420,  425,  426 

Veins,  air  in,  195 

■  emissary,  of  skull,  13 

of  Galen,  37 

— —  valves  in,  196 

(see  also  various  regions) 

Venesection  at  elbow,  276 
Venous  sinuses,  32 

tumours  of  skull,  15 

Vertebra  prominens,  165 
Vertebrae,  caries  of,  370 
■  dislocation  of,  633 

fracture  of.  633 

— —  fracture  -  dislocation  of, 
634 

■  movements  of,  628 

Vertebral  artery,  195 

■  canal,  congenital  mal- 
formations of,  650 

fluid  tumour  of,  650 

— —  points     of      exit      of 

nerves  from,  647 

■  column,  627 

■  sprains  of,  630 

■ (see  also  Spine) 

Vesico-vaginal  fistula,  489 
Viscera,  abdominal,  nerve  sup- 
ply of,  440 

thoracic,  213 

Visceral  nerves,  348 

'  supports,  380 

Visceroptosis,  378 
Viscus,  dilatation  of,  383 
Vitello-intestinal  duct,  340,  392 
Vitreous  humour,  71,  73 

foreign  bodies  in,  73 

" table,"  25 

Vocal  cords,  181 
Vomiting,  severe,  in  spinal  in- 
juries, 650 
Vulva,  466 


676 


SURGICAL  APPLIED  ANATOMY 


"  Weaver's  bottom,"  507 
Wharton's  duct,  144 
White  line  at  anus,  498 

■ in  pelvic  fascia,  452 

Whitlow,  314 
Winged  scapula,  240 
Winslow,  foramen  of.  376 
Wirsung,  duct  of.  425 
Wormian  bones.  21 
Wrist,  300 
Wrist-joint,  301 


Wrist-joint,  amputation  at,  323 

■  dislocations  at,  321 

•  fractures  about.  318 

movements  of,  317 

strength  of,  316 

surface  anatomy  of,  300 

Wry-neck,  170 

Zygoma    as    guide    to    struc 

tures,  12 
■  fracture  of,  12 


Printed  bv  Cajssell  &  Company,  Limited,  La  Belle  Sauvage,  London,  E.G. 


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ration of  loan  period. 


Library  o!  the 
University  of  California  Medical  School  and  Hospitals 


